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HX64146812 
RC61  .W24  The  student's  guide 


RECAP 


Columbia  ^ntbn^tt|) 
tntI)e(Citp0tUttogork 

(taiU^  of  Phgstrtana  anb  ^urg^anH 


G.  L.  PEABODY 


THE  STUDE^S'T'S   GUIDE 


TO 


CLINICAL    MEDICINE 


AND 


CASE-TAKING 


BY 


FKAXCIS  WARXER,  M.D.  Lond.,  F.RC.P. 

ASSISTANT    PHYSICIAN,    LECTURER    ON     BOTANY,    AND    LATE    MEDICAL   REGISTRAR    TO    THE 
LONDON     HOSriTAL;      LATE    PHYSICIAN    TO    THE    EAST     LONDON    HOSriTAL     iOR    CHILDREN 
EXAMINER   TO   THE    UNIVERSITY    OF   ABERDEEN 


SECOND  EDITION 


PHILADELPHIA 

P.    BLAKISTON,     SON    &    CO. 

1012,    WALXUT     STREET 

1885 


INTKODUCTIOX  TO  SECOND  EDITION 


FuRTHEE  experience  gained  since  the  publication  of  the  former 
edition,  has  shown  that  students  commencing  clinical  work 
need  to  be  taught  to  think,  and  reason  for  themselves,  as  well  as 
to  observe.  It  is  hoped  that  the  plan  of  this  work  tends  to 
give  such  training  if  properly  used. 

The  size  of  this  work  has  not  been  increased,  but  new 
material  has  been  added,  and  corrections  have  been  made  in 
accordance  with  the  advances  of  clinical  medicine,  especially  in 
the  chapter  on  diseases  of  the  nerve-system.  A  special  scheme 
for  taking  notes  of  children  has  been  added,  and  the  index  has 
been  made  more  complete. 

F.  W. 
24,  Harley  Street,  W. 

December,  1884. 


miKODUCTIOX  TO  FIRST  EDITION. 


DuEiNG  the  three  years  that  I  held  the  office  of  Medical 
Registrar  to  the  London  Hospital,  I  saw  that  the  student,  on 
commencing  his  duties  as  clinical  clerk,  required  some  guide 
as  to  the  method  of  arranging  the  history  of  his  case,  and  the 
facts  observed.  A  card  of  "instructions  for  case-taking" 
was  provided,  almost  similar  to  that  given  at  page  xi.  It  was 
further  evident  that  with  each  case  the  student  needed,  when 
taking  his  cases,  to  be  told  what  special  points  to  note  iu 
the  history,  and  what  special  points  to  look  to  under  each 
of  the  heads  of  the  "instructions."  Further,  zeal  was  much 
stimulated  in  the  thoughtful  student  by  telling  him  why  these 
special  points  should  be  enquired  for,  and  their  presence  or 
absence  noted. 

Such  points,  with  regard  to  the  more  commonly  recurring 
diseases,  have  been  put  together,  and  presented  in  the 
following  pages. 

The  object  has  been  to  provide,  in  a  small  space,  a  guide  for 
the  student  to  use  at  the  bedside,  when  wanting  to  know 
what  to  look  for,  and  what  to  note.  Pathology  and  treatment 
are  not  touched  upon,  and  for  this  reason,  independent  of 
the  general  incompleteness  of  this  little  work,  the  student 
is  recommended  to  read,  in  some  text-book,  all  about  his 
case  in  hand.  Much  attention  has  been  given  to  the  special 
conditions  met  with  in  disturbance  and  disease  of  the  nervous 
system. 


vi  INTRODUCTION. 

To  encourage  enquiry  as  to  the  origin  of  disease,  the 
principal  causes  in  each  case  are  indicated  under  the  heading 
"causation,"  which  will  usually  be  found  on  the  left-hand 
page,  sometimes  on  the  right-hand  ;  thus  the  student  may  find 
his  enquiries  directed  on  reasonable  grounds.  As  to  the  scheme 
of  the  work,  as  far  as  possible  the  facts  indicated  as  specially 
to  be  observed  are  arranged  under  the  ordinary  heads  of  a  case 
on  the  left-hand  page,  and  on  the  corresponding  right-hand 
page  are  given  explanations,  characters  of  the  special  disease, 
or  points  of  interest  in  its  natm'al  history,  etc.  This  plan 
could  not  in  all  cases  be  adhered  to,  and  general  convenience 
and  the  necessities  of  printing  had  then  to  take  precedence  of 
the  original  scheme. 

Names  printed  in  the  text  in  thick  type  are  heads  of  chapters 
contained  in  the  work,  which  may  be  found  on  reference  to  the 
index.  Thus,  in  taking  a  case  of  fever,  look  for  "Signs  of 
Fever,"  and  if  Vomiting  or  Jaundice  be  present  look  up  these 
heads  by  means  of  the  index. 


F.  W. 


24,  Harley  Street,  W. 
1881. 


CONTENTS. 


TAVrV. 

Instructions  for  Case-taking  ....        xi — xiii 

Additional  Instructions  for  Children's  Cases      xiv,  xv 

Table    Showing    Healthy    Development    of    an 

Infant xvi 

General  Diseases — Class  I. 

Common  bad  Hygienic  Conditions — Signs  of  Fever — 
Table  of  the  Specific  Fevers  :  Enteric  Fever  ;  Typhus  ; 
Scarlet  Fever  ;  Measles  ;  Variola  ;  Varicella — Erysipelas 
—  Diphtheria  —  Pyaemia  —  Puerperal  Fever  —  Ague — 
Hooping-cough — Syphilis,  inherited  ;  Syphilis,  acquired  1 — 17 

General  Diseases — Class  IL 

Signs  of  Defective  Development — Anaemia ;  Pernicious 
Anaemia — Cancer — Rickets—  Emaciation  — (Edema  or 
Anasarca — Amyloid  Degeneration — Scrofulosis  :  General 
Miliary  Tuberculosis — Table  of  Differences  and  Resem- 
blances between  Enteric  Fever  and  Tuberculosis — 
Diabetes  Mellitus — Addison's  Disease — Purpura — De- 
velopmental Defects — Senile  Degeneration     .         ,         .19 — 33 

Arthritic  Diseases. 
Arthritis — Rheumatoid  Arthritis — Table  of  Joints  for 
Description — Rheumatism  ;   Gqaiorrhceal  Rheumatism — 
Gout 34-39 


Vni  CONTEXTS. 


Diseases  of  the  Nervous  System. 


PAGE 


General  Conditions  of  the  Xervous  System  —  Intel- 
ligence —  Speech  —  Sleep  —  Head-pain  —  Headache  — 
Vomiting — Coma  — Vertigo  —  Delirium — Typhoid  State 
— Paralysis — -Tendon  Reflexes — Skin  Reflexes — Table  of 
Diagnosis  of  Functional  from  Organic  Paralysis — Elec- 
tric Tests — Convulsion — Spasm — Laryngismus — Tremor 
-  Athetosis — Motor  Power — Sensation — Muscular  Anses* 
thesia — Special  Senses — Cranial  Nerves — Bell's  Paralysis 
of  the  Face — Brain  Disease — Ophthalmoscopic  Appear- 
ances— Pupils — Signs  of  Spinal  Cord  Disease — Minor  Para- 
lyses :  Progressive  Muscular  Atroph}' ;  Pseudo-hyper- 
trophic  Paralysis  ;  Paralysis  of  Extensors  of  Forearm  ; 
Cross  Paralysis  ;  Bulbar  Paralysis  ;  Paralysis  of  Face — 
Neuralgia  :  Sciatica  ;  Intercostal  Neuralgia — Hemiplegia 
- — Chorea — Table  of  Diagnosis  of  Chorea  from  Sclerosis — 
Hysteria  ;  Epilepsy ;  Table  of  Diagnosis  of  Epilepsy 
from  Hysteria — Cerebral  Tumour — Cerebral  Meningitis — 
Chronic  Hydrocephalus — Table  of  Diagnosis  of  Hydro- 
cephalus from  Rickets— Alcoholism- —Acute  Alcoholism — 
Delirium  Tremens — Insanity— General  Paralysis  of  the 
lasane— Paralysis  Agitans — Sclerosis  of  the  Cord — Te- 
tailus — Locomotor  Ataxy— Infantile  Paralysis — Graves' 
Disease  — Plumbism  — Diphtheritic  Paralysis — Herpes 
Zoster 40—101 

Diseases  of  the  Vascular  System. 

Physical  Examination  of  the  Heart  :  Pulse  ;  Passive 
Congestion — Important  Anastomoses — Table  of  Signs  of 
Valvular  Lesions,  Mitral  Regurgitation  and  Obstruc- 
tion ;  Aortic  Regurgitation  and  Obstruction  ;  Hj'per- 
trophy  and  Dilatation  of  the  Heart — Cardiac  Displace- 
ments— Valvular  Disease — Heart  Disease  —  Table  of 
Diagnosis  of  Functional  from  Organic  Palpitation — Angina 
Pectoris — Pericarditis — Congenital  Defects  of  the  Heart 
— Tricuspid  Regurgitation — Thoracic  Aneurism — Disease 
of  Vessels     .,,,,,,.        102—123 


CONTENTS. 


Diseases  of  the  Respieatory  System. 


PAGE 


Clinical  Regions  of  tlie  Chest — Physical  Examination 
of  the  Chest — Auscultation — Cough — Sputum  —  Hemo- 
ptysis ;  Table  of  Diagnosis  of  Heemoptysis  from  Hiema- 
temesis — -Dyspnoea — Pulmonary  (Edema — Contraction  of 
Lung — Solidification  of  Lung — Table  of  Diagnosis  of 
Pneumonia  from  Pleuritic  Effusion  —  Pleurisy;  Em- 
pyema ;  Hydrothorax  —  Phthisis  —  Pneumonia  —  Em- 
physema— Bronchitis — Asthma — Laryngeal  Diseases.  124 — 149 


Diseases  of  the  Digestive  System. 

Signs  of  Digestive  Functions  :  Appetite — Intestinal 
Worms  —  Examination  of  the  Mouth  and  Throat : 
Tongue  ;  Palate  ;  Tonsils  ;  Pharynx  ;  Teeth  ;  Gums — 
Diarrhcea — Vomiting  —  Acute  Abdominal  Pain  —  Dys- 
phagia —  Htematemesis  —  Meltena  —  Obstruction  of  the 
Bowels — Gastric  Ulcer — Typhlitis — Abdominal  Cancer  : 
Cancer  of  Stomach  ;  Cancer  of  Intestines  — Ulceration  of 
Bowels  :  Dysentery  ;  Tubercular  Ulceration — Abdominal 
Tumours  :  Ovarian  ;  Kidney  ;  Spleen  ;  Abdominal 
Aneurism;  Tumours  arising  from  the  Pelvis  —  Faecal 
Accumulations —  Phantom  Tumour  —  Intussusception — 
Examination  of  Abdomen — Fluid  in  Peritoneum — Dia- 
gnosis of  Ovarian  Tumour  from  Ascites — Peritonitis  .  150 — 173 


Diseases  of  the  Liver. 

Jaundice  ;  Table  of  Causation  ;  Jaundice  from  Ob- 
struction or  Independent  of  Obstruction — Large  Livers  : 
Lardaceous,  Fatty,  Hydatid — Cancer  of  the  Liver — 
Small  Livers — Acute  Yellow  Atrophy — Cirrhosis  of  the 
Liver — Syphilitic  Disease  of  the  Liver — Gall-Stones  ; 
Biliary  Colic— Hydatid  of  Liver     ....       174—18^ 


CONTEXTS. 


Diseases  or  the  Up.inary  System. 

PAGE 

Bii^t's  Disease  —  Uraemia  —  AlbtuaiiLiiria  —  Hsma- 
tmia — ^Paroxysmal  Haematuria — Acute  Briglit's  Disease 
— GiamilaT  Contracted  Eidneys — Fatty  Kidneys — Amy- 
loid and  Laige  White  Eidneys — Briglit's  Disease,  Acute 
or  Chroiiic — ^Disrases  of  the  Bladder — Renal  Calculus  ; 
Benal  Colic — ^Description  of  Urine  ;  Examination  of  the 
Deposit,  ChemieaUj  and  Microscopically — Normal  Con- 
stitn^Lts  of  the  Urine ;  Abnormal  Constituents  j  Albu- 
men, Sngar,  Bile,  Leucine,  Tyrosine — ^Urinarj'^  Calculi 
—Mnrexide  Test  for  Uric  Acid      .         .         .         .       184—203 

SlGXS     OF      PBEGlfAJfCY  —  COESrCIDENT       SiGXS       AXD 

Symptoms     .......        204,  205 

I>-DEX  . 206—211 


INSTRUCTIO]S"S     FOR     CASE-TAKING. 


I.  Enter  name,  age,  occupation,  address,  date  of  admission 
to  hospital,  and  date  at  which  the  notes  were  taken, 

II.  State  what  the  patient  complains  of,  as  far  as  possible 
using  his  own  words.  With  children  say  what  the  friends 
complain  of, 

III.  Family  History. — Number  and  condition  of  health  of 
those  living.  Ages  and  diseases  of  those  dead.  Specially 
enquire  as  to  points  in  the  inheritance  bearing  on  the  case 
and  its  causation. 

Personal  History. — Habits,  occupations,  residences, 
previous  illnesses  and  diseases.  Indications  of  scrofula, 
gout,  rickets,  syphilis,  etc.     Give  dates. 

History  of  Present  Illness. — Date  and  manner  of  com- 
mencement ;  date  when  last  at  work.  Order  of  the 
occurrence  of  symptoms,  with  date.  Indicate  the  day  of 
illness  on  the  temperature  chart.  In  taking  this  history 
look  up  the  causation  and  course  of  the  disease  as  given 
in  the  text.    Probable  causes. 

IV.  Present  Condition. — General  condition.  Intelligence; 
mental  state  ;  sleep  ;  complaints  of  pain,  etc.  Nutrition  ; 
emaciation  ;  anaemia ;  oedema ;  complexion  ;  any  specially 
obvious  abnormal  condition  or  source  of  distress,  etc. 
Position  of  patient  in  bed  ;  orthopnoea  ;  dorsal  decubitus  ; 
etc.  Pulse  =  ;  Temperature  =  ;  Respirations  =  ; 
Weight  =     . 


Xll  INSTRrCTIOXS   FOE    CASE-TAKING. 

Lymphatic  Glands  in  neck,  axilla,  groins ;  size,  hardness, 
mobility  ;  tendency  to  suppuration. 

Locomotor  System. — State  of  bones,  muscles,  joints,  scars, 
nodes.     Skin,  dry  or  moist  ;  bed-sores. 

Y.  l^ervous  System. — General  Condition.  Intelligence  ; 
sleep  ;  speech.  Vertigo  ;  head-pain.  Delirium ;  paralysis  ; 
convulsion ;  tremor  ;  coma,  etc. 

Motor  Foiver. — Ability  to  stand  or  work  ;  movements 
of  extremities  ;  gait  in  walking  ;  co-ordination  of  limbs. 
Eeflezes, 

Sensibility. — Tactile  sensibility  of  skin  ;  sensibility  to 
beat  and  cold,  also  to  pricking.  Anaesthesia  ;  hyper- 
ffistbesia  ;    dyssesthesia.     Special  senses. 

Cranial  Nerves. — Movements  of  eyes,  tongue,  palate, 
face.     State  of  pupils.     Ophthalmoscopic  examination. 

YI.  Vascular  System. — Pulse,  frequency  and  other  characters  ; 
condition  of  the  vessels,  especially  the  arteries.  Cyanosis. 
Heart ;  palpate,  auscultate,  percuss.  ^STote  precordial 
dulness  if  normal.  Palpitation,  pain  or  signs  of  heart 
disease. 

YII.  Respiratory  System, — Dyspnoea,  frequency  and  charac- 
ters of  the  respiratory  movements.  Cough  ;  expectoration  ; 
hsemoptysis. 

Physical  Exariiination. — -Inspection;  palpation;  percus- 
sion ;  auscultation.  Signs  of  bulging  or  contraction  of 
chest  or  solidification  of  lungs,  etc.     Larynx. 

YIII.  Digestive  System. — Tongue;  teeth;  throat.  Appetite  ; 
thirst.  Vomiting ;  haematemesis ;  melaena.  State  of 
bowels  ;  tenesmus  ;  griping  ;  piles.  Fulness  or  pain  after 
food .;  flatulence  ;  pyrosis ;  colic  or  other  disturbance. 
Abdominal  pain  or  tenderness, 


INSTP.rCTIOXS   FOR   CASE-TAKING.  Xlll 

ii  ye /'.—  Size  and  general  characters  as  determined  by 
percussion  and  palpation :  whether  tender  or  not, 
Jaundice. 

Spleen. — Size  as  determined  by  percussion  and  pal- 
pation. 

Abdomen. — Physical  examination.  Whether  tender,  dis- 
tended, retracted.     Ascites.     Tumour. 

IX.  Urinary  System. — TJrine,  quantity,  colour,  reaction,  Sp. 
gr.  Albumen,  bile,  sugar.  Deposit,  its  general,  chemical, 
and  microscopical  characters.  Frequency  of  micturition  ; 
if  accompanied  by  pain  ;  heematuria. 

X.  Generative  System. — Menstraation  :  frec|uency  ;  duration  ; 
quantity  increased  or  otherwise  ;  whether  painful ;  other 
discharges.     Conditions  of  uterus  and  pelvic  organs. 

XI.  Treatment. — Prescriptions  and  diet,  etc.,  should  be 
entered  in  the  notes,  and  all  alterations  noted,  with 
the  dates. 

XII.  Diagnosis.  —  Should  enumerate  the  principal  disease, 
secondary  lesions,  complications  and  specially  important 
conditions,  symptoms  or  points  in  the  treatment. 


ADDITIONAL    INSTRUCTIONS    FOR 

CHILDREN'S    CASES. 


II.  State  complaints  made  concerning  the  child,  or  obvious 
conditions  of  disease. 

III.  Family  History. — Number  and  condition  of  health  of 
those  living.  Ages  and  diseases  of  those  dead.  Specially 
enquire  as  to  the  inheritance  bearing  on  the  case. 
History  of  mother's  health  during  the  intra-uterine  life  of 
the  child.     Note  any  miscarriages,  Avith  dates. 

Personal  History.  —  Whether  healthy  at  birth  ;  how 
brought  up  ;  if  suckled  ;  if  farinaceous  food  has  been  used. 
Previous  illnesses,  and  diseases. 

IV.  Present  Condition. — General  condition:  plumpness;  skin 
elastic,  clear  or  muddy  looking,  with  aged  appearance. 

Condition  of  Development. — Anaemic  ;  hsemorrhagic  flea 
bites  ;  sweating.  Bones,  feel  them  all  while  the  child  is 
stripped.  Signs  of  syphilis,  rickets,  etc.  Note  Avarmth 
of  the  limbs  ;  whether  the  child  sheds  tears  in  crying. 
T.  =       ;    P.  =       ;    R.  =       ;    "W.  =  .      Signs  of 

defective  development. 

V.  Nervous  System. — General  condition.  Note  the  amount 
of  movement  of  limbs,  hands,  and  feet,  or  whether  this  is 
absent.  Intelligence,  as  indicated  by  movements  of  face 
and  eyes  directed  towards  objects  noticed.  Sleep  ;  making 
noises  ;  consciousness  ;  exhaustion  ;  coma.  Paralysis  ; 
examine  each  limb.     Spasm  ;  tremor  ;  contraction. 


ADDITIONAL   INSTRUCTIONS   FOR   CHILDREN  S   CASEUS.        XV 

Motor  Power. — Reflex  action  on  tickling  hands,  putting 
finger  in  mouth,  etc.  Playfulness  ;  ability  to  laugh. 
Power  over  large  joints,  small  joints,  movements  of 
fingers,   etc. 

Cranial  Nerves. — Movements  of  eyes  and  face. 

Head.  —  Its  shape  and  circumference.  Fontanelle  is 
patent,  prominent,  or  depressed.  State  of  other  sutures. 
Ophthalmoscope. 

VI.  Vascular   System.  —  Pulse  :    frequency    and    character. 
Cyanosis.     Heart :  palpate,  percuss,  auscultate. 

VII.  Respiratory  System. — Dyspnoea;  frequency  of  respiratory 
movements ;  laryngeal  stridor,  spasm,  or  obstruction. 
Warmth  or  coldness  of  breath.     Cough. 

Physical  PIxamination.  —  Inspection  ;  signs  of  collapse 
at  bases  and  clavicular  regions.  [To  examine  back,  let 
child  be  held  leaning  over  nurse's  shoulder.]  Palpation  ; 
rhonchi  may  sometimes  be  felt.  Percussion.  Aus- 
cultation. In  children,  and  especially  infants,  the  feeling 
of  resistance  of  lung,  or  its  elasticity  beneath  the  finger 
struck,  gives  valuable  information  as  to  its  consolidation  or 
clearness. 

VIII.  Digestive  System, — Tongue,  lips,  throat  ;  state  of  den- 
tition. Appetite  and  liking  for  food  ;  how  it  is  fed. 
Vomiting.  State  of  bowels.  Abdomen  :  whether  full  or 
empty  ;  palpate  ;  note  size  of  liver  and  spleen.  State  of 
umbilicus.  Pain  after  food  ;  flatulence  ;  abdominal  ten- 
derness ;  griping  of  bowels.  Test  milk  used  for  cream  and 
acidity. 

'        In  examining  an  infant,  it  is  necessary  to  determine  if 
it  be  well  developed.     See  Developmental  Defects. 

The  child  should  be  weighed,  and  the  circumference  of 
the  head,  at  its  longest,  should  be  measured. 


XVI       ADDITIONAL    IX.STIiUCTlON.S   FOR   CHILDREN"  S    CASES. 

Tlw  fulloicing  Table  is  for  a  licalthy  well-developed  infant  of 
good-class : — 

Infant  at  birth  -weighs  six  to  ten  pounds  ;  head  circum- 
ference, 11  "15 — 12'5  inches. 


S«   I        Points    indicating    Stage    and   Progress    of 
M  s   i  Development. 


I. 

II. 

III. 


lbs.  j   ins.  j 

7tolOj  14 "5   I  Power  to  suck;  regular  succession  of  feeding  and 

sleeping  ;  hand  reflex. 
11  "0    15*25  '  Hair  in  eyelashes  and  eyebrows  ;  may  be  occasional 

strabismus. 
13-5     16-5      Capability  of  shedding  tears ;  no  strabismus. 


IV.  15*0  I  17"0      Constant  movement  while  awake. 

V.  j  15*5  I  17"0      Turning  head  to  a  light  or  sound. 

t  ! 

VI.  I  16*0  1 17 "25    Pi.ecognizing  objects,  as  mother,  nurse. 

VII.  !  17*5  j  17"5  Holding  object  in  hand,  and  carrying  it  to  mouth. 

VIII.  !  18 "5  ;  17 '75  Various  sounds  made  ;  commencing  dentition. 

IX.      19"5  \  IS'O  Some  power  to  hold  up  head  Avhen  lying  do-^^Ti. 

X.    i  19'6    18'25  Holding  an  object  without  dropping  it. 

XI.  I   19'7  i  18"4   '  Power  to  transfer  object  from  one  hand  to  the  other. 

j  I 

XII.  20"0     18*5   i  Commencing  to  crawl  or  stand  with  assistance. 


THE 

STUDENT'S  GUIDE  TO  CLINICAL  MEDICINE. 


GENEKAL  DISEASES— CLASS  I. 

Specific  diseases  caused  by  semie  poison  received  by  tJie 
patient  from  without,  andj  in  many  cases  communicable  from 
one  patient  to  another. 

COMMON  BAD   HYGIENIC   CONDITIONS. 

Drawing  drinking-water  from  a  cistern  over  w.c. 

Overflow  pipe  from  a  cistern  opening  into  a  sewer  or  soil-pipe 
instead  of  into  open  air. 

Drain  from  a  kitchen  sink  opening  direct  into  a  sewer  or  cess- 
pit instead  of  into  open  air  over  a  drain. 

Want  of  proper  traps  cutting  off  house-sewer  from  street-sewer, 
and  each  soil-pipe  from  house-drain. 

Want  of  ventilation  of  house-drains  and  soil-pipes,  with 
arrangements  for  access  of  air  into  them,  and  exit  of  sewer- 
gas  from  them,  may  cause  foul  smells. 


2  CLINICAL   MEDICINE   AND   CASE-TAKING. 

FEVER,  SIGNS  OF. 

General  condition. — Temperature  raised  ;  respirations  and  pulse 
frequent  ;  skin  diy  and  hot,  or  sweating  ;  rigors  ;  fever: 
pains  ;  acMng  in  back  and  limbs  ;  prostration  of  muscular 
power  ;  face  presents  depressed  look.  P,  =  ;  T.  =  ; 
R.  =     . 

Mode  of  onset. — Sudden,  with  rigors,  headache,  pains  in  back 
and  limbs  ;  gradual,  with  anorexia  and  thirst,  loss  of 
strength. 

Digestion. — Anorexia  ;  thirst ;  bowels  confined  or  relaxed  ; 
describe  the  motions  passed.  Tongue  furred,  dry,  or 
moist ;  papillse  may  be  enlarged.  State  of  gums  ;  teeth. 
Throat ;  tonsils.  Vomiting,  Spleen  may  be  enlarged. 
lAver,  see  Jaundice. 

Vascular  system. — Pulse  frequent,  soft,  may  be  dicrotous  and 
intermittent.  Heart's  action  quick  ;  note  strength  of 
impulse  and  first  sound.  Tendency  to  capillary  con- 
gestion. 

Respiratory  system. — Respirations  frequent ;  tendency  to  con- 
gestion of  the  lungs.  Pulmonary  (Edema;  Bronchitis; 
Pneumonia;  Pleurisy. 

Nervous  system. — Mental  condition,  see  general  condition  of 
Nervous  System.  Sleep  ;  Headache ;  Delirium ;  Typhoid 
State. 

Urine. — Scanty.  Sp.  gi".  high.  Commonly  a  deposit  of 
Lithates.  It  may  be  jaundiced  or  albuminous.  Urea  may 
be  in  excess. 

Look  for  rash  and  the  characters  of  the  Specific  Fevers ;  local 
and  general  complications. 


GENEKAL   DISEASES — GLASS    I, 


FEVER,  SIGNS  OF. 


General  condition. — An  exanthematous  fever  does  not  often 
recur  in  the  same  individual.  The  date  and  mode  of  onset 
are  important,  so  also  whether  sudden  or  gradual,  with 
or  without  rigors. 


Digestion. — Sordes  and  accumulations  of  mucus  may  occur 
on  lips  and  teeth.  Note  any  inability  to  take  food  or  to 
swallow.  Jaundice  is  common  in  relapsing  fever,  and 
may  be  present  with  Pyaemia,  Typhus,  etc. 


Vascular  system,  see  Pericarditis. — Danger  may  arise  from 
failure  of  heart's  action,  and  weakness  of  the  circulation. 
Note  complexion  of  the  lips  and  face,  fulness  and  tension 
of  pulse. 

Pkespiratory  system. — Note  fulness  or  shallowness  of  respirations. 
Examine  lungs  fi'equently,  even  if  there  be  no  symptoms 
of  their  disturbance.     Note  cough  or  Expectoration. 

Nervous  system. — Mental  condition  disturbed  ;  delirium  not 
necessarily  of  bad  prognosis.  Hyperpyrexia  and  ady- 
namia dangerous. 

Urine. — Albuminuria  may  be  temporary,  or  it  may  lead  to 
chronic  Bright' s  disease. 


Look  for  causation  ;  cold,  contagion  in  case  of  specific  fevers, 
bad  hygienic  conditions. 

Causation. — Contagion  ;  concurrent  or  previous  illness  in  same 
house ;  smells  from  sewers ;  water  supply  ;  date  of 
exposure  to  contagion  ;  infection  by  clothes. 


CLINICAL   MEDICINE   AND    CASE-TAKING, 


SPECIFIC    ERUPTIVE    FEVERS. 


DAYS  OF  FEVER  AND  RASH. 

ENTERIC  FEVER.— Onset 
gradual  ;  temperature  slowly 
rising,  falling  at  end  of  3rd  or 
in  the  4tli  week  with  exacer- 
bations at  night.  Small  oval 
hypersemic  spots  on  abdomen 
in  successive  cro^^s  in  2nd  and 
early  in  3rd  weeks. 


SIGNS   AND   SYMPTOMS. 

Abdominal  pain  and  ten- 
derness; gurgling  over  cae- 
cum. Bowels  usually  relaxed. 
Spleen  large.  Temperatm'e 
may  be  excessive.  Occasion- 
ally sudamina.  Bronchitis 
common.  Bowels  may  be 
constipated. 


TYPHUS  FEVER.  — Onset 
severe,  with  rigors  and  pains  in 
back  and  limbs.  Temperature 
rises  rapidly  4  to  5  days, 
falling  about  14th  day.  Mul- 
berry-coloured maculae,  at 
first  slightly  raised,  then  dull 
mottling,  appear  in  1st  week, 
disappear  end  of  2nd  week. 

SCARLET  FEVER.— Onset 
rather  sudden,  with  chilliness. 
Temperature  rising  rapidly. 
Rash  2nd  day  on  neck,  chest, 
and  trunk,  extending  to  the 
limbs  ;  minute  red  points, 
quickly  becoming  a  diffused 
erythema.  Rash  passes  off 
about  7th  day,  leaving 
desquamation  of  skin.  Tem- 
perature falls  about  same 
time. 


Headache  and  nervous 
symptoms  prominent  ;  de- 
lirium usual.  Much  tendency 
to  heart  failure  and  hypo- 
static congestions.  Bron- 
chitis. Bowels  not  usually 
relaxed. 


Tongue  thickly  coated, 
with  enlarged  red  papillae 
protruding  ;  tip  quickly  be- 
coming red.  Fauces  inflamed  ; 
tonsillitis.  Desquamation 
specially  seen  on  hands  and 
feet.  Occasionally  there  is 
no  rash.     Delirium. 


GENEEAL  DISEASES — CLASS    I. 


SPECIFIC    ERUPTIVE    FEVERS. 


COMPLICATIONS. 

ENTERIC  FEVER.— Signs  of 
heart  failure.  Delirium. 
Typhoid  State.  Hypostatic 
congestion  of  lungs.  Albu- 
minuria. Hsemorrliage  from 
bowels  ;  perforation  of  intes- 
tine. Profuse  sweating,  see 
Tuberculosis.  Phlebitis.  Se- 
quential abscesses.  Tendency 
to  relapses  of  fever  and 
other  symptoms. 

TYPHUS  FEVER.— Active  Deli- 
rium passing  into  the  Typhoid 
State.  Hypostatic  pneu- 
monia. Albuminuria.  "Weak 
action  of  ventricles,  and 
very  soft  pulse. 


CAUSATION. 

Impure  water.  Sewer 
gas.  Probably  not  con- 
tagious, but  by  the  evacua- 
tions. Note  occupation  ; 
residence,  and  its  hygienic 
condition  ;  sources  of  milk 
supply. 


Contagious  from  the  sick 
to  the  healthy.  Its  spread 
is  favoured  by  over-crowding, 
bad  hygienic  conditions,  and 
starvation. 


SCARLET  FEVER.— Albumi- 
nuria and  ansemia  with  ana- 
sarca from  Acute  Bright' s 
Disease.  Inflammation  of  the 
throat  may  be  excessive,  with 
ulceration.  Arthritis.  Scarla- 
tinal rheumatism.  Inflam- 
mation of  the  middle  ear. 
Glandular  abscess  in  neck. 
Hyperpyrexia.  Pleurisy  or 
empyema  rather  than  pneu- 
monia. Convulsions.  Scarlet 
Fever.  —  Rheumatic  symp- 
toms often  commence  at 
the  beginning  of  the  2nd 
week  with  swelling  in  sheaths 
of  tendons,  and  some  redness, 
tenderness,  and  moisture  of 
skin.  Subsequently  stiff"  neck 
not  uncommon. 


Highly  infectious,  especi- 
ally through  the  dust  of 
the  skin.  The  type  varies 
greatly  in  diff'erent  epi- 
demics ;  in  some,  greater 
tendency  to  complications 
or  death. 


CLINICAL   MEDICINE   AND    CASE-TAKING. 


SPECIFIC   FEVERS. 


DAYS  OF  FEVER  AND  RASH. 

MEASLES.  —  Rash  appears 
about  4th  day  ;  begins  on 
face,  spreading  to  the  trunk 
aud  limbs.  Fine  red  points, 
becoming  flat  and  forming 
crescentic  patches.  Tempera- 
ture begins  to  fall  two  or 
three  days  after  rash  appears. 


SIGNS   AND   SYMPTOMS. 

Specially  common  in  chil- 
dren. Onset  with  chills  or 
rigors.  Sleepiness.  Catarrh  ; 
conjunctivee  watery  ;  coryza. 
If  rash  is  full,  desquamation 
mav  follow. 


VARIOLA.— Rash  appears  3rd 
day,  fii'st  on  forehead  as  red 
papules,  soon  becoming  vesi- 
cles, feeling  hard  as  shot  ; 
5th  day  they  become  umbili- 
cated  and  purulent ;  8  th  day 
pustules  mature,  then  scab. 
Temperature  rises  rapidly ; 
falls  as  rash  appears  ;  secon- 
dary fever  vith  the  suppura- 
tion. 


Incubation  after  inocula- 
tion, 7  days  ;  after  infection, 
12  days.  Onset  with  great 
pains  in  limbs  and  back. 
Rigors.  Vomiting'.  The 
pustules  may  become  con- 
fluent or  remain  distinct. 


VARICELLA.— With  onset, 
small  red  spots  appear  on 
trunk,  face,  scalp,  becoming 
resides,  but  these  are  not 
cellular  or  umbilicated  ;  they 
crust.  Temperature  not  high. 


Very  little   constitutional 
disturbance. 


GENEEAL   DISEASES — CLASS   I. 


SPECIFIC   FEVERS. 


COMPLICATIONS. 

MEASLES.— Mostly  in  respi- 
ratory system.  Bronchitis. 
Acute  broncho  -  pneumonia, 
which,  may  become  chronic. 
Laryngitis  may  be  severe ;  it 
precedes  the  rash.  There  may 
be  vomiting  and  diarrhoea. 
Delirium.  Rarely  cutaneous 
haemorrhages.  Occasionally 
Albuminuria. 


CAUSATION. 


Very  infectious,  especially 
during  the  eruptive  stage. 


VARIOLA.  —  Mucous  surfaces 
frequently  affected,  especially 
conjunctivae,  throat,  nose. 
Bronchitis  ;  Pneumonia  ; 
Pleurisy  ;  diarrhoea  ;  Albu- 
minuria ;  abscesses.  Cuta- 
neous haemorrhages  and 
bleeding  from  the  mucous 
surfaces,     Typhoid  State. 


Very  infectious.  Inocul- 
able  by  pus  of  vesicles,  also 
by  scabs. 


VARICELLA.— Ifone  are  usual. 


Infectious. 


CLOnCAI.  MEDIdSTE  AlO)  CASE-TAKING. 


ERYSIPELAS. 

Tj.,     -:i::      ::   ::^  /;-'_rr     mncli    swollen,    red, 

i:o"iis ,    "rViiti^ei   ZL.^    i_.i:^:r.5   of  the  inflaTned  part 
rimed  or  diffiiaed.      3^::^    :-.-r--    Tesieles    or    buBsB. 
::;    ralaiged  tymphalic  glands.     I^ote    signs    and 
mi  of  Fever. 


CemfiiMa&m&. — CeUnliiis  ;  alisoess;  gangvene.  Ddirinn.;  the 
Ijrplioid  State;  ADbaniKiiria;  FBeuuniiB;  FletoiBy; 
FUeUtis;  FeiietiriitiB;  tedeaiia  of  lazynx;  infamina- 
tioM  of  £aiiD^u     Diaxdioea. ;  relapses  of  the  disease. 


DIPEIHEEIA, 

Q<-  :;  :Lr  :  2.7:t:.:  .  i';.!:?;"  to  swallow,  strengtli of 

voiee,   Djspaicea,    3 '-it.::.    : :    body.       P.  =        ;  T.  =        ; 

R.=      .      "Rya. ^    2£:-j.iii  and  Throat  for  redness  and 

sweDing  of  Uit  :i:  r-  soft  palate,  nvnla,  pharynx; 
paibGlies  of  meii-  :  i :. :  :  -  ^r^idation,  wMtisli  or  greyish, 
oflbeaa  mnlltiple  :  i:.t"_i.  i^i-t  id  ay  be  peeled  off,  leaving 
smrfeffle  of  imac:'i.?  iiTi_::i"-:-r  raw,  but  not  ex<^vated. 
Zxi-iir.-^  Ir;  =    : It -"_•:-,  r:;::-^.  .-'.ir. is  Hinder  the  Jaw.     Note 

igeal  Bisease. 


-     T    ,.  . 


iMrymt^ooA  sym^^wis. — CommeiMaiig  with  a  short  eongh,  and 
-■_i:lt  li:^:"i'— '  ::"  ^'r. h^^i:sL2  :  "':reathii!g  noisy,  stridnlous, 
—  :1  1,  iir'illi-v-:  ;:.  l::.^-  : : :  ^-.i  :  weak  voice;  straggling 
:  :  ::riT'_  l...  -  i::;:;;^!-  :  :'...t~:  c-oHapsing  ;  pnlse  weak; 
i^It  ':'_:.:-':.  :  rrTiri-^Lnes  cold  ;  sweating.  Note  if  trache- 
iTiii"'.'  .:  ■:  :_i_  11 ::_-::.  or  not. 


— Faenumia;  Flemisy;  Mbaadnnxia;  adynamia 
il^raae  on  oomjnnctiva  and  ^in  ;  Faralysis. 


GENERAL   DISEASES — CLASS    I. 


ERYSIPELAS. 


An  acute  febrile  disease  characterized  by  local  diflFiised  inflamma- 
tion of  skin  and  cellular  tissue  with  bullse  and  vesiculation. 
Idiopathic  erysipelas  usually  attacks  the  face,  commenc- 
ing about  the  eye. 


Causation. — Epidemic  and  endemic  causes.  Exposure  to  cold, 
and  bad  hygienic  conditions ;  contagion.  It  may  follow 
injury  or  operation.  Those  once  attacked  by  the  disease 
are  liable  to  recurrence. 


DIPHTHERIA. 

A  febrile  contagious  disease,  characterized  by  the  formation  of 
membranous  exudations  on  the  fauces  and  respiratory 
mucous  membrane,  frequently  obstructing  the  larynx, 
often  attacking  the  mucous  membrane  of  the  nose  and 
causing  an  acrid  discharge.  It  is  asthenic  in  its  course, 
and  attended  by  gi'eat  debility,  frequently  proving  fatal 
through  Laryngeal  Obstruction  or  by  pneumonia.  The 
period  of  incubation  is  various.  It  may  commence  with 
lassitude,  febrile  disturbance,  sore -throat  ;  or  those  pre- 
liminary symptoms  may  be  absent,  laryngeal  stridor  being 
the  first  symptom  noticed.  Sometimes  swelling  of  the 
glands  under  the  jaw  first  attracts  attention.  There  may 
be  membrane  in  the  larynx,  and  none  on  the  fauces. 
There  is  less  pain  on  attempting  to  swallow  than  with 
quinsy.  Fever  not  prominent ;  rarely  runs  high.  When 
paralysis  follows,  it  is  usually  after  convalescence. 

Causation. — Communicable  from  the  diseased  to  the  healthy 
by  secretion  of  mouth,  vomits,  expired  air.  Bad  water  ; 
sewer  gas,  and  bad  hygienic  conditions.  Most  common  in 
children.     It  may  be  epidemic  or  endemic. 


10  CLINICAL   MEDICINE   AND    CASE-TAKING. 

PYEMIA. 

Examine  the  body  all  over  for  any  wound,  local  inflammation, 
or  suppuration.  A  very  slight  wound  may  produce  the 
disease,  e.g.,  a  thorn  under  the  nail,  etc.  See  Signs  of 
Fever  and  General  Condition  of  the  Nervous  System, 
prostration.  Coma,  Typhoid  State. 

Causation.  — Suppui'ation  connected  with  diseased  bone  ;  whit- 
low ;  Phlebitis  ;  softening  clots  ;  ulceration  from  tertiary 
syphilis ;  Periostitis.  Occasionally  it  is  secondary  to 
internal  suppuration  or  ulceration,  e.g.,  enteric  fever, 
gastric  ulcer,  abscess  of  kidney,  etc. 

ComjMcations. — Occasionally  a  cutaneous  erythema.  Jaundice, 
without  signs  of  obsti-uction  ;  Albuminuria ;  haemorrhages 
in  skin  or  from  mucous  membranes.  Low  forms  of 
inflammation  ;  Pericarditis  ;  Pneumonia  ;  Pleurisy  ;  em- 
pyema ;  Peritonitis. 

PUERPERAL   FEVER. 

GeTieral  condition. — General  signs  of  Fever.     Patient  usually 

assumes  the  dorsal  decubitus.     There  is  much  tendency  to 

adynamia   and    the    Typhoid    State,    with  sweating  and 

Delirium. 
Ahdoriicii. — Usually  distended   and  tympanitic  ;    bowels  often 

costive.     There  may  be  local  tenderness  over  the  uterus 

or  in  either  iliac  fossa. 
Genito-iirinary  system. — Xote  pain  or  difiiculty  on  micturition 

or  defsecation.     Lochial  discharge,  its  amount,  if  off'ensive  ; 

any   clots   or  pieces   of    placenta   or    membranes   passed. 

Albuminuria.  Breasts,  if  milk  is  secreted  ;  condition  of  the 

glands,  tenderness. 
Causation. — Epidemic   at   periods.     Endemic    in    a  house    or 

hospital ;  due  to  inoculation  by  nurse  or  attendant,  e.g.,  from. 

a  case  of  erysipelas,  or  another  puerperal  case.     Infection 

with  an  acute  specific  fever,  e.g.,  scarlet  fever.     Local  septic 

poisoning  from  metiitis,  decomposing  clobs,  or  portions  of 

placenta.     Bad  hygienic  conditions. 


GENERAL   DISEASES — CLASS   I.  11 

PYJEMIA. 

Usually  commences  by  an  insidious  onset,  or  with  chilliness  or 
rigors,  and  fever  with  sweating  and  great  prostration.  It 
is  characterized  by  the  formation  of  multiple  abscesses,  and 
arthritis  with  a  tendency  to  suppuration  in  or  around  the 
joints.  The  tendency  is  to  death  by  exhaustion,  the 
patient  passing  into  the  typhoid  state,  or  by  its  com- 
plications. It  may  be  mistaken  for  Eheumatism  or 
Enteric  Fever,  or  ma}^  be  confounded  with  broncho- 
pneumonia, which  often  accompanies  it.  Any  source  of 
suppuration  may  lead  to  the  disease,  whether  the  pus  be 
discharged,  as  from  an  open  abscess,  or  retained  in  deep 
parts,  as  from  periostitis  and  acute  necrosis. 


PUERPERAL  FEVER. 

An  acute  febrile  disease,  probably  of  septic  origin,  following 
shortly  after  confinement,  and  incommunicable  to  those  not 
in  the  puerperal  state.  The  onset  occurs  about  2nd  or 
3rd  day  after  confinement,  with  chilliness  or  rigors,  and 
the  signs-  of  Fever.  Usually  this  is  attended  with  scanty 
and  offensive  uterine  discharges.  The  secretion  of  milk  is 
often  suspended,  but  what  is  formed  does  not  hurt  the 
infant. 

Complications. — Pleurisy.  Empyema.  Pneumonia.  Pericarditis. 
Albuminuria.  Pelvic  cellulitis  or  parametritis.  Peritonitis. 
Mammary  abscess.  Phlebitis,  or  phlegmasia  dolens. 
Arthritis. 

Varieties  of  Fever. — It  may  be  specially  characterized  by 
Peritonitis ;  by  pelvic  cellulitis  ;  metritis,  with  much 
abdominal  pain  and  tenderness.  Simple  fever,  with 
alteration  of  secretions,  but  no  other  local  manifestations  ; 
the  fever  tending  to  exhaustion,  adynamia,  and  the 
Typhoid  State. 


12  CLINICAL   MEDICINE   AND   CASE-TAKING. 

AGUE. 

Enquire  as  to  the  periodicity  of  the  paroxysms.  Describe  ar 
attack,  giving,  if  possible,  the  duration  of  the  stages. 
Note  conditions  of  health  in  the  inter-paroxysmal  period. 
Paroxysms  may  occur  daily — quotidian ;  with  one-day 
interval — tertian  ;  mth  two-days  interval — quartan.  Note 
general  appearance  and  condition  ;  whether  Anaemia  or 
cachexia.  Examine  optic  discs  :  sometimes  hsemorrhages 
are  seen  in  the  retina.  Urine.  T.  =  ;  R.  =  ;  P.  =  . 
Also  note  condition  of  Spleen  and  liver.  General  condition 
of  the  Nervous  System. 

ComjMcoMons     mul    Sequelce. — Enlargement     of  spleen     and 

occasionally  liver  ;  digestive  organs  disturbed.  Dysentery  ; 

jaundice ;    Anaemia ;    melansemia    (pigment  granules    in 

blood)  ;     retinal     hemorrhages ;     cachexia  ;  Neuralgia ; 
brow-ague. 

Causation. — Endemic,  in  low  and  ill-drained  districts. 
Symptoms  may  follow  in  a  few  hours  after  imbibing 
the  poison,  or  may  be  delayed. 


HOOPING-COUGH. 

Geiiera.l  condition. — State  of  nutrition  ;  look  for  signs  of  Rickets. 
P.  =  ;  T.  =  ;  R,  =  ;  W.  =  ,  Enquire  for  signs  of 
catarrh  preceding  the  development  of  hooping ;  simple 
cough,  with  expectoration,  running  at  nose,  etc. 

Respiration. — Physical  examination  of  lungs  ;  the  chest,  its 
shape  and  movements,  signs  of  collapse.  Cough  ; 
paroxysms,  describe  them,  their  frequency,  duration,  and 
mode  of  subsidence  ;  note  the  amount  of  asphyxia  and 
venous  congestion. 

Complicatimis. — Pulmonary  collapse  ;  specially  in  cases  of 
Eickets,  which  usually  do  badly.  Bronchitis  and  broncho- 
pneumonia ;  Convulsions ;  Diarrhoea.  Epistaxis  ;  blood 
often  ejected  from  mouth. 


GENERAL   DISEASES — CLASS   I.  13 

AGUE. 

Characterized  by  feverish  paroxysms,  recurring  at  regular 
intervals,  the  patient  being  well  between  the  paroxysms. 

Paroxysm. — 1.  Cold  stage:  Lassitude,  headache,  malaise,  chilli- 
ness, shivering,  passing  on  to  rigors,  the  teeth  chattering 
and  limbs  trembling  ;  muscular  pains  ;  epigastric  discom- 
fort ;  goose-skin  ;  face  dusky,  pinched,  shrunken.  Pulse 
small  ;  respirations  quick  ;  temperature  rising  rapidly. 

2.  Hot  sta.ge  :  Rigors  and  chilliness  disappear,  succeeded  by  a 
comfortable  warmth  ;  face  less  shrunken.  Patient  then 
feels  hot  ;  flushes  ;  there  may  be  mental  excitement.  Skin 
dry  and  frequently  hot ;  pulse  full  and  strong  ;  respirations 
more  rapid.  Headache.  Temperature  rises  higher.  Urine 
abundant. 

3.  Sweating  stage  :  Feeling  of  heat  diminishes  ;  temperature 
falls.  Skin  becomes  moist  and  sweating  profuse.  Pulse 
and  respiration  fall  in  frequency.  Headache  passes  off. 
Patient  feels  easy  and  sleeps,  awaking  feeling  well.  Urine 
scanty,  depositing  lithates. 

Temperature  may  rise  without  a  developed  paroxysm. 

HOOPING-COUGH. 

Characterized  by  paroxysms  commencing  with  a  series  of 
expiratory  coughs,  followed  by  deep,  full  inspiration  with 
loud  laryngeal  spasm.  Frequently  vomiting  and  expecto- 
ration with  paroxysms.  Child  may  be  comparatively  well 
in  intervals.  Asphyxia  in  paroxysms  very  great ;  this  may 
lead  to  ecchymosis  under  conjunctiva.  Sublingual  ulcer  often 
results  from  stretching  the  fraenum  over  the  lower  incisors 
during  paroxysms.  Ejection  of  blood  not  a  bad  symptom. 
Look  for  any  spasmodic  signs,  such  as  Tetanus  or  chronic 
spasmodic  conditions  of  muscles  of  one  extremity  ;  this  is 
almost  entirely  confined  to  Rachitic  children.  Enquire  as 
to  a  source  of  contaffion. 


14  CLI>:iCAL   MEDICINE   AND   CASE-TAKING. 


SYPHILIS— Inherited. 


General  condition. — Unhealthy  aspect ;  dull  earthy  complexion  ; 
old  and  shrivelled  appearance.  Rash  on  skin ;  erythe- 
matous patches  with  abrupt  margins ;  coppery  tint. 
Squamous  skin  lesions  about  mouth,  chin,  limbs,  soles  of 
feet.  Sometimes  a  scab  or  a  pustular  rash  with  bullse  ; 
there  may  be  much  desquamation.  The  skin  about  nates 
and  mouth  mostly  aifected.  Nails  may  be  unhealthy  and 
chippy. 


Mucous  membranes. — Mucous  tubercles  or  condylomata  at  anus 
and  at  angles  of  the  mouth  ;  diffuse  stomatitis  ;  inflamma- 
tion of  gums  and  tooth-sacs.  Thrush.  Discharge  from 
nose,  often  excoriating  the  lip  ;  snuffles.  Laryngitis ;  voice 
or  cry  hoarse. 


Viscera  may  be  affected  :  spleen  large ;  liver. 


Bmies. — Periostitis  may  be  very  extensive,  causing  much 
deformity  of  limbs  and  thickening  of  the  skull.  Skull 
thick  ;  forehead  prominent  ;  craniotabes.  Swelling  of  ends 
of  long  bones  just  above  epiphyses. 

Nervous  system. — Deafness  (nerve  disease)  and  amaurosis  more 
common  than  with  the  acquired  disease  ;  palsy  of  a  single 
nerve  less  common  ;  occasionally  epilepsy  or  imbecility. 


GENERAL  DISEASES — CLASS  I.  .15 


SYPHILIS— Inherited. 

This  may  lead  to  deposit  of  gummata. 


Eyes. — May  be  early  the  seat  of  iritis,  later  of  keratitis,  which 
occurs  towards  adult  life  and  is  usually  symmetrical. 
There  may  also  be  choroiditis. 


Nose. — Mucous  membrane  swollen  ;  this  leaves  nose  sunken  and 
flattened.  Occasionally,  in  severe  cases,  the  skin  disease 
is  obvious  at  birth,  but  usually  child  appears  perfectly 
healthy  till  about  six  weeks  old  ;  the  thrush  and  the  rash, 
etc.,  then  appear. 


Marks  left  in  adult. — Bridge  of  nose  sunken  in  ;  linear  scars 
near  angles  of  mouth  and  about  anus.  Interstitial 
keratitis  ;  iritis ;  choroiditis.    Prominent  forehead* 


Nerve  deafness. — Often  only  slight  and  temporary ;  in  some 
absolute  and  permanent. 


Teeth. — All  the  incisors  may  be  dwarfed  and  malformed. 
The  upper  central  incisors  are  most  reliable,  dwarfed, 
usually  narrow  and  short,  with  atrophy  of  the  middle  lobe, 
leaving  a  single  broad  vertical  groove. 


16  CLINICAL   MEDICINE   AND    CASE-TAKING. 


SYPHILIS — Constitutional  and  Acquired. 

Stages  : — Incubation  ;  efflorescence  ;  decline  ;  relapse  ;  sequelae. 
General  condition.  — Tendency   to  emaciation  ;  debility  ;  vague 
pains.     Anaemia.     Look  for  scar  of  primary  sore. 


Digestion. — Mucous  tubercles  of  lips  ;  sores,  leaving  scars,  at 
angles  of  mouth.  Tongue,  Soft  Palate,  pharynx  ;  ulceration 
on  tonsils.  Superficial  and  symmetrical  ulcers  in  first 
stage  ;  deep,  destroying  parts,  when  tertiary  ;  destruction 
of  these  parts.  Ulceration  and  condylomata  of  anus. 
Liver,  perihepatitis  ;  gummata. 

Besjiiration. — Laryngeal  Disease  with  ulceration  and  tendency 
to  contraction.     Lung  disease  of  chronic  character. 

JVervotis  system. — Disease  of  Brain  or  Spinal  Cord.  Gummata, 
forming  tumour  in  brain.  Palsy  of  Cranial  Nerves, 
especially  nerve  iii.  and  nerve  vi.  ;  disease  of  auditory 
nerve.  Iritis  ;  choroiditis  ;  retinitis.  Meningitis  ;  pre- 
disposition to  Ataxy. 

Locomotor  system. — Nodes  and  thickening  of  bones  ;  Periostitis. 
Skin  :  syphilides,  psoriasis,  serpiginous  tubercular  patches, 
ulcers  with  ragged  edges,  etc. 

Lymphatic  glands. — Generally  enlarged  in  neck  and  groins, 
without  tendency  to  suppuration. 

Special  phenomena. — Gummatous  masses  in  viscera  and  skin, 
etc.  Condylomata  and  mucous  patches  on  mucous 
membranes,  or  ulceration  with  tendency  to  contracting 
scars.     Disease  of  testes. 


GENERAL  DISEASES — CLASS   I.  17 


SYPHILIS* — Constitutional  and  Acquired. 

These  phenomena  may  be  considered  as  occurring  in  the  second 
and  third  stages. 


SecoTid  stage. — Follows  six  weeks  to  two  months  after  inocula- 
tion. Rash  on  skin,  scattered  coppery  eruption  ;  or  it 
may  be  scaly,  papular,  pustular,  rather  on  flexor  than 
dorsal  aspect.  On  mucous  membranes  symmetrical  ulcers, 
tonsils  especially,  with  abrupt  edges  ;  condylomata  may 
form  anywhere.  Iritis  usually  symmetrical.  Occasionally 
slight  periostitis. 


Third  stage. — Tendency  to  unsymmetrical  ulceration  of  skin 
and  mucous  membranes,  with  great  tendency  to  relapse. 
Scars  tend  to  contraction  and  pigmentation.  Tendency 
to  sloughing. 


Bone    disease. — Periostitis,    nodes,    chronic   thickening, 
destruction  of  nasal  and  palatal  bones. 


Gummata  may  form  in  any  viscus.  In  liver  they  may 
be  felt  during  life  ;  in  brain  may  cause  signs  of  tumouk  ; 
in  skin  may  lead  to  extensive  sloughing. 


Arteries  often  diseased.  This  may  lead  to  aortic 
Aneurism,  minute  arterial  aneurisms  in  brain,  and 
haemorrhage,  Thrombosis,  and  gangrene. 

*  Mr.  Hutchinson's  Article— Reynolds'  "System  of  Medicine." 


GENEEAL    DISEASES— CLASS    II. 

Diseases  often  inherited,  frequently  arising  from  some  internal 
changes  in  the  patienf s  tissues  or  organs,  hut  often  due  to  causes 
acting  from  ivithout. 

SIGNS  OF  DEFECTIVE  DEVELOPMENT. 

Search  for  accompanying  congenital  defects  of  development. 
Defect  of  heart  ;  cleft  palate  ;  deformity  of  hands  or 
feet ;  supernumerary  fingers  and  toes  ;  epicanthic  folds  in 
excess  ;  unusual  shapes  of  the  ears,  and  asymmetry  between 
the  two  ears  ;  coarse  or  ichthyotic  skin  ;  hair  on  forehead. 
Abnormal  conditions  of  head  ;  size  and  shape  ;  fontanelle 
and  sutures,  whether  open.  They  are  sometimes  pre- 
maturely ossified,  and  the  forehead  prow-shaped.  Eye  : 
Coloboma  ;  congenital  defect  of  sight.  Undescended 
testicle ;  hydrocele  ;  hernia.  Skin :  Coarse,  ichthyotic  ; 
deficient  in  elasticity  ;  increased  areolar  tissue  ;  extremi- 
ties blue  ;  chilblains. 

Description. — But  little  spontaneous  movement  ;  dirty  habits  ; 
fits ;  paralysis  ;  inability  to  hold  head  up,  to  talk  or 
walk.  In  low-class  cases  repetitive  movements  are  com- 
mon, e.g.,  continuous  movement  of  one  arm,  purposeless 
and  rhythmical ;  absence  of  intelligence  ;  not  attracted  by 
light  or  sound. 

Lungs. — Liability  to  bronchitis. 

Nervous  system. — Defective  in  intelligence  ;  convulsions  ; 
defective  motor  power  ;  insuf&cient  power  of  co-ordina- 
tion. 

Causation. — Syphilis  ;  drunkenness  in  parents  ;  relationship 
between  the  parents.  Most  common  in  first  member  of  a 
family. 


20  CLINICAL   MEDICINE   AND    CASE-TAKINQ. 

ANEMIA. 

Pallor  of  skiu  and  mucous  memlDranes,  lips,  aud  conjunctivae. 
When  the  fingers  are  held  up  to  the  light  the  redness  of 
the  borders  is  seen  diminished.  (Edema  of  feet ;  possibly 
puffiness  of  face.         ^ 

Circulation. — Examine  arteries  and  veins  in  the  neck  ;  condition 
of  heart.  See  condition  of  the  blood  and  its  microscopical 
characters.     Look  for  Diseases  of  Vessels.     Breathlessness. 

Nervous  system. — Headache;  Neuralgia,  especially  spinal; 
intercostal  nem-algia  ;  drowsiness  ;  mental  weakness  and 
irritability  ;  muscular  weakness  ;  pains  in  back.  Examine 
optic  discs. 

Me7istrv^Mo7i. — Disordered  ;  usually  lessened,  or  absent. 

Look  for  Pernicious  Anaemia,  leucocythsemia,  enlarged  glands, 
cancer,  hsemori'hages  from  mucous  membranes  or  under 
skin  ;  heart  disease  ;  chronic  lung  disease  ;  Bright' s 
Disease.  Examine  urine.  Examine  liver  and  spleen. 
T.  =     :  P.  =     :  R.  =     :  W.  =    . 


PERNICIOUS   (Progressive)  ANEMIA. 

Look  for  general  signs  of  anaemia,  and  the  ordinary  causes.  See 
amount  of  redness  of  the  fingers  held  before  a  strong  light. 
Examine  optic  discs  ;  there  may  be  retinal  haemorrhages. 
Note  condition  of  the  joints  and  general  power  of  the 
patient  ;  also  state  of  digestion. 

CANCER. 

Geiural  conditio7i. — Anaemia;  cachexia;  Emaciation;  loss  of 
muscular  strength.     Temperature  not  raised. 

Disturbed  functimi  of  ^jar^s  affected. — Pressure  signs  from 
growth  of  mass,  e.g. — (1)  Glands  in  transverse  fissure  of 
liver  obstructing  the  vena  portse  and  causing  Ascites,  or 
the  duct,  causing  jaundice  ;  (2)  Mediastinal  tumour  ;  (-3) 
Pressure  on  veins,  e.g.,  vena  cava  or  iliac  veins  ;  (4)  Intra- 
cranial tumoui'  ;  (5)  Annular  stricture  of  intestine. 


GENERAL   DISEASES — CLASS   II.  21 

ANiEMIA. 

Circulation. — Over  jugular  vein,  especially  on  the  right  side,  a 
thrill  may  be  felt  with  the  fingers,  particularly  in  children  ; 
but  this  does  not  necessarily  indicate  anaemia.  A  con- 
tinuous humming  sound  heard,  Bruit  de  Diable,  over 
jugular  like  wiind  among  trees,  varying  with  the  pressure 
of  the  stethoscope.  Systolic  blowing  over  the  carotid  or 
subclavian  artery  on  very  slight  pressure.  Over  the 
pulmonary  (2nd  left)  costal  cartilage  a  systolic  bellows, 
the  second  sound  being  often  sharp  and  accentuated. 
Heart's  action  quick  ;  easily  excited  to  palpitation.  Pulse 
soft  and  frequent. 

Causation. — Haemorrhage  ;  menorrhagia.  Sequent  to  acute 
disease.  Defective  hygienic  surroundings.  Hot  rooms. 
Want  of  good  food  regularly  taken.  Dyspepsia  ;  chronic 
gastric  disease;  Alcoholism;  Plumbism;  mental  exhaus- 
tion ;  fright  ;  Malaria ;  heart  disease  ;  Cancer ;  often  due 
to  over-long  lactation  ;  general  delicacy  ;  disturbed  nights 
as  well  as  lactation  ;  re-establishment  of  menstruation 
during  lactation.  Coincident  disease  ;  Bright's  disease 
sequent  to  pregnancy ;  rapid  development  of  phthisis,  which 
was  quiescent  during  pregnancy. 

PERNICIOUS  (Progressive)  ANiEMIA. 

Profound  increasing  aneemia,  accompanied  by  increasing 
debility  and  prostration,  tending  to  death  in  many  cases. 

Haemorrhages  ;  spongy  gums  ;  epistaxis  ;  breathlessness  ;  palpi- 
tation on  exertion.  Fat  of  the  body  not  absorbed  ;  the 
subconj  unctival  fat  yellowish .  Excretion  of  urea  diminished . 
There  may  be  irregular  pyrexia. 

CANCER. 

Causation. — Hereditary  ;  declining  period  of  life  ;  sequent  to 
blows.  Organs  commonly  affected — uterus,  mammse,  liver, 
stomach,  peritoneum,  other  abdominal  sites,  lungs. 

Secondary  deposits. — In  liver,  from  the  rectum,  sigmoid  flexui'e, 
stomach,  etc.  In  lymphatic  glands  next  to  the  organ 
affected. 

Complications.  —  Serous  effusion  ;  adjacent  inflammations  ; 
thrombus  of  veins. 


22  CLINICAL   MEDICINE   AND   CASE-TAKING. 

RICKETS. 

Eaquire  as  to  conditions  of  feeding ;  ability  to  stand  or  walk ;  age 
at  "wMch  walking  commenced  ;  previous  health,  especially 
as  to  symptoms  and  complications  of  rickets.  Examine 
bones,  head,  abdomen.     Anaemia. 

Bo>ie$. — Ribs  beaded  ;  enlargement  of  ends  of  ribs  at  their 
junction  with  the  cartilages.  Sternum  thrust  forward  by 
the  falling  in  of  the  ribs  at  side  of  chest ;  hypochondriac 
regions  depressed.  Spine  may  be  bent  backwards,  but  is 
capable  of  being  sti'aightened  on  suspending  the  body, 
lifting  the  child  by  the  arms.  Shaft  of  long  bones  often 
bent,  especially  in  tibiae  if  child  has  walked  ;  epiphysis 
enlarged,  particularly  in  radius.  Skull  may  remain  patent 
long  after  the  first  year  ;  the  head  is  large,  wide,  and  flat 
on  the  vertex.  See  diagnosis  from  Chronic  Hydrocephalus. 
Head  may  be  small  and  not  ill-shapen.  Craniotabes,  or 
soft  spots  viith  deficiency  of  bone,  can  be  felt  sometimes 
in  the  occipital  bone. 


EMACIATION. 

History  as  to  probable  causation.  Emaciation,  whether  gradual 
or  sudden,  or  coincident  -with  other  signs  of  disease.  Dis- 
tribution of  the  emaciation,  especially  in  children.  The 
emaciation  often  afiiects  the  body  and  extremities  more 
than  the  head  and  neck.  Examine  all  the  organs  and 
urine.  Kote  weight  of  patient,  and  record  it  once  a  week. 
Specially  enquire  as  to  histoiy  of  phthisis.  Look  for 
Anaemia,  and  the  signs  of  any  disease  supposed  to  have  pro- 
duced the  emaciation.  When  a  muscle  is  stinick,  e.g.,  biceps, 
note  its  irritability,  longitudinal  contractions,  and  ti'ans- 
verse  knotting. 

Kidritioii  indicated  by  the  relation  of  age,  height,  weight,  etc. 
W.  =  .  Spare,  thin,  emaciated,  stout,  fat,  good  muscular 
development,  strong,  weak. 

Growth  rapid,  moderate,  slow. 


GENERAL   DISEASES — CLASS   II.  23 

RICKETS. 

Thickening  and  deformity  of  bones.  The  child  may  be  fat  or 
ill-nourished.  Much  tendency  to  sweating,  especially 
about  the  head ;  throws  off  the  clothes  at  night ;  head  much 
rubbed  on  the  pillow,  so  that  hair  is  worn  from  occiput. 
Dentition  late  ;  the  teeth  often  devoid  of  enamel — soon 
decaying.  General  tenderness,  so  that  child  cries 
on  being  moved.  Late  in  walking.  Late  signs :  Head 
large,  flat,  square  ;  figure  too  small  in  the  legs. 

Complications. — Tendency  to  catarrh  of  intestines  ;  diarrhoea; 
abdomen  large  and  prominent ;  Spleen  and  liver  large. 
Bronchitis ;  collapse  of  base  of  lungs.  If  Hooping-Cough 
supervenes,  it  runs  an  unfavourable  course  with  bronchitis  ; 
Convulsions  and  Laryngismus. 

Causation. — Ill-feeding  during  infancy,  especially  with  farina- 
ceous food  ;  intestinal  catarrh  ;  bad  hygienic  conditions : 
premature  birth. 

Digestion. — Teeth  late  in  appearing,  and  often  deficient  in 
enamel  ;  abdomen  large,  prominent,  tympanitic,  partly 
owing  to  weak  condition  of  its  muscles. 

Nervous  system. — Liability  to  convulsion;  laryngismus;  tetany, 
or  chronic  contraction  of  muscles  of  extremities. 


EMACIATION. 

Causation. — Chronic  lung  disease  ;  Phthisis  ;  caseous  bronchial 
glands.  Cancer.  Chronic  stomach  disease  ;  Diarrhoea  ; 
Vomiting.  Starvation  and  ill-feeding,  especially  in 
infants.  Defective  hygienic  conditions.  Senile  Degenera- 
tion. Sequent  to  acute  disease.  Fever.  Diabetes.  General 
Tuberculosis.  Disturbance  of  the  general  condition  of  the 
Nervous  System. 


In  infants  often  called  Marasmus.  Look  for  signs  of  Congenital 
Syphilis ;  collapse  of  lungs  ;  Rickets.  See  state  of  skin  ; 
fulness  or  retraction  of  abdomen.  State  of  bowels  ;  con- 
stipation or  chronic  diarrhoea.  State  at  birth,  if  suckled  ; 
how  fed,  and  nature  of  foods.     Thrush. 


24  CLINICAL   MEDICINE   AND   CASE-TAKING. 


(EDEMA  OE  ANASARCA. 

Anaemia.  Signs  of  disease  of  heart  or  vessels.  Look  fox 
Cardiac  Dilatation  or  degeneration. 

Lungs. — Especially  empliysema  or  phtliisis. 

Urine.— See  signs  of  Bright's  Disease. 

If  anasarca  be  thought  to  be  due  to  passive  congestion,  look 
for  the  signs  of  passive  congestion,  and  note  if  the  oedema 
lessen  or  increase  •with  such  other  signs  ;  e.g.,  note  if  oedema 
lessen  with  the  disappearance  of  pulmonary  oedema,  etc. 
If  anasarca  be  due  to  Bright's  disease,  note  if  it  lessen 
with  lessening  Albuminuria,  and  increase  of  the  quantity 
and  sp.  gr.  of  the  urine. 


AMYLOID   DEGENERATION. 

Pasty,  anaemic  appearance.     Anasarca. 

Liver. — Large,  firm-edged,  uniformly  enlarged,  smooth. 
Usually  no  jaundice  or  ascites. 

S^ileen. — Large,  firm,  smooth. 

Kidneys. — Urine  very  albuminous.     Anasarca. 

Intestines.  — Diarrhoea. 

CoALsaMon. — Syphilis.  Chronic  suppuration.  Phthisis,  with 
suppuration  of  bronchi.  Chronic  disease  of  bone,  see 
Scrofula. 


GENEKAL  DISEASEg-^CLASS  II.  25 


(EDEMA  OR  ANASARCA. 

Causation — 
Obstruction  at  heart. — Passive  (Cardiac)  Congestion.    Cardiac 
valvular  disease  ;  failure  of  the  ventiicles  ;  fatty  heart ; 
dilated  right  ventricle.     Adherent  pericardium. 

Obstruction  at  lungs. — Emphysema.  Chronic  bronchitis. 
Conditions  obstructing  circulation  in  one  lung,  e.g., 
chronic  pleurisy,  empyema,  collapse  of  one  lung. 

Local  pressure  on  veins. — Pressure  on  vena  cava  or  iliac  veins 
in  abdomen  from  enlarged  glands,  Cancer,  Aneurism, 
pregnancy.  Abdominal  Tumour,  pelvic  effusion  ;  pres- 
sure from  ascites.  Pressure  on  subclavian  vein  from 
thoracic  aneurism  or  mediastinal  tumour. 

Changes  in  blood  or  vessels. — Bright's  Disease.  Anaemia ; 
extreme  debility  from  chronic  disease,  e.g.,  cancer, 
Phthisis,  diarrhoea  in  children,  Phlebitis,  phlegmasia 
dolens,  varicose  veins. 

SCROFULA. 

General  condition. — W.  =  ;  T.  =  ;  R.  =  ;  P,  =  .  Intelligence 
dull ;  phlegmatic  temperament.  Coarse,  flabby,  ungainly 
children,  outlines  of  body  ill-marked.  Features  plain, 
complexion  pasty.  Liable  to  ophthalmia  ;  tinea  tarsi ; 
otorrhcBa,  eczema,  lichen,  lupus,  chilblains,  blue  hands. 
Forehead  and  back  hairy. 

Respiratory  system. — Liability  to  bronchitis  and  chronic  pneu- 
monia passing  on  to  Phthisis. 

Digestive  system. — Abdomen  full ;  liability  to  diarrhoea.  Teeth, 
no  distinctive  condition,  liable  to  decay,  may  be  devoid 
of  enamel.  Upper  lip  thick.  Gums  unhealthy.  Tonsils 
large. 

Locomotor  system. — Bones  thick  ;  joint  disease  frequent.  Skin 
easily  inflamed.  Glands  enlarged  and  suppurate,  specially 
in  neck. 


26  CLINICAL  MEDICINE  AND  CASE-TAKING. 


GENERAL  MILIARY  TUBERCULOSIS. 


General  condition. — Look  for  signs  of  strumous  disease  in  bones, 
joints,  spine  ;  enlarged  glands  ;  Emaciation ;  state  of  skin. 
P.  =     ;  T,  =     ;  R.  =     .     Look  for  Signs  of  Fever. 

Respiratory  system. — Signs  of  Consolidation  of  Lung  or 
Phthisis ;  enlarged  bronchial  glands  ;  cough. 

Digestive  system. — Vomiting;  state  of  bowels,  see  Ulcer ation 
of  Bowels  ;  ability  to  take  food. 

Nervous  system. — Signs  of  Meningitis ;  signs  of  Brain  Disease. 
Ophthalmoscopic  examination  may  show  optic  neuritis 
or  tubercles  in  choroid.  Tubercle  in  choroid  indicates 
tuberculosis,  not  meningitis  ;  optic  neuritis  with  tubercle 
indicates  probable  tubercular  meningitis. 

The  onset  may  be  insidious,  with  a  previous  period  of  emaciation 
and  lassitude,  and  after  a  few  days  or  weeks  may  be 
followed  by  the  somewhat  sudden  onset  of  a  special 
complication,  as  Pneumonia ;  Meningitis.  The  general 
symptoms  are  mostly  prostration,  Emaciation,  sweating, 
cough,  moderate  fever — this  may  be  absent.  Some  of  the 
complications  are  usually  present,  and  frequently  there 
are  the  signs  of  old  strumous  disease.  The  disease  tends 
to  death  by  exhaustion  or  by  complications.  The  presence 
of  miliary  tubercles  in  the  lungs  does  not  necessarily  cause 
any  abnormal  physical  signs. 


GENERAL  DISEASES — CLASS   II. 


27 


ENTERIC   FEVER    resembles    GENERAL   MILIARY 


Diarrhoea      from      typhoid 

ulceration  of  Payer's  patches. 

I.    Evening    exacerbations    of 

fever,    mostly  in  3rd  or  4th 

Aveeks. 

III.  Profuse  sweating,  with 
great  debility  and  prostra- 
tion. 

IV.  Bronchitis  and  pneumonia 
common  complications. 

V.  Emaciation  from  fever. 

VI.  Mental  dulness  from  fever. 


TUBERCULOSIS. 

Diarrhoea  from  tubercu- 
lar disease  of  intestines. 

Remittent  hectic  fever 
common,  with  caseous  lung 
or  glands,  etc. 

Profuse  sweating  a  part 
of  the  natural  course  of  the 
disease. 

Chronic  pneumonia  may 
set  up  general  tuberculosis. 

Emaciation  from  tubercu- 
losis. 

Commencing  Meningitis. 


DIAGNOSTIC   DIFFERENCES. 


I.  Characteristic  rash  on  the 
abdomen,  etc. 

II.  Diarrhoea  and  abdominal 
symptoms  prominent. 

III.  Spleen  often  large. 

IV.  Lung  symptoms  late  in 
appearing. 

V.  Delirium  and  exhaustion, 
proportioned  to  height  and 
duration  of  fever. 

VI.  Occurs  in  those  previously 
healthy. 

VII.  Profuse  sweating  less 
common. 

VIII.  High  fever. 

IX.  History  of  individual  and 
family  healthy. 

X.  Any  age. 


No  exanthem.  Skin  may 
be  erythematous  ;  or  suda- 
mina. 

Bowels  usually  consti- 
pated. 

Spleen  usually  normal 
size. 

Lung  symptoms  appear 
early. 

Definite  signs  of  menin- 
gitis. 

Usually  previous  lung 
disease. 

Sweating  usual. 

Fever  not  high. 
Individual  or  family  scrof- 
ulous. 

Usually  young. 


28  CLINICAL   MEDICINE   AND    CASE-TAKING, 


DIABETES   MELLITITS. 

General  conditimi. — Emaciation;  weakness.  Skin  harsh  and 
dry.  Mental  aberration  ;  low  spirits.  See  Nervous 
System. 

Digestion.  —  Appetite  gi'eatly  increased  ;  intense  thirst. 
Tongue  frequently  devoid  of  epithelium,  raw  and  cracked. 
Bowels  costive  ;  sometimes  diarrhoea. 

TJrine. — Quantity  usually  greatly  increased ;  greenish  colour  ; 
high  sp.  gr.  ;  sugar  abundant.     Micturition  frequent. 

Causation. — Most  common  in  males  and  middle-aged  adults  ; 
frequent  in  phthisical  families.  Exposure  to  cold. 
Alcoholism ;  excessive  use  of  sugar  ;  violent  emotional 
disturbance ;  organic  Brain  Disease ;  over  mental  Avork  or 
anxiety.     It  may  be  associated  with  Gout. 


ADDISON'S  DISEASE. 

General  condition. — Debility,  faintness,  pigmentation.  Antemia. 
Frequently  tubercular  tendency.  Shallow,  feeble  breath- 
ing ;  breathlessness,  sighing,  gasping,  especially  on 
any  effort.  T.  =  ;  usually  subnormal.  If  not  compli- 
cated, no  emaciation.  Feeble  heart  action,  faintness,  pulse 
thready.  Death  by  asthenia,  sudden  or  preceded  by 
incoherence,  delirium,  convulsions. 

Digestion. — Nausea,  retching,  Vomiting,  epigastric  pain. 
Examine  buccal  mucous  membrane  and  that  of  lips. 
Hiccough ;  anorexia. 

Nervous  system. — Its  general  condition.  Pains  and  sleeplessness. 
Loss  of  nerve -muscular  power  ;  extreme  depression. 


GENERAL   DISEASES — CLASS   II.  29 


DIABETES   MELLITUS. 

Characterized  by  excessive  tliii'st,  excessive  hunger,  emaciation. 
Urine  saccharine,  dense,  and  greatly  increased  in  quantity, 
as  a  constant  occurrence.  Saccharine  urine  may  be  tem- 
porary, as  after  a  convulsion  or  administration  of  chloro- 
form. Diabetes  is  the  more  permanent  condition  of 
glycosuria,  with  constitutional  symptoms  and  a  tendency 
to  certain  complications  ;  it  usually  has  a  fatal  tendency. 
Onset  of  symptoms  may  be  insidious  or  sudden,  with 
nervous  disturbance.  Sugar  may  be  detected  in  sweat, 
tears,  saliva. 

Urine. — The  quantity  of  sugar  usually  greatest  after  food. 
Glucose  may  temporarily  disappear  ;  so  also,  not  uncom- 
monly, shortly  before  death. 

CoonpUcaticms.  —  Broncho-pneumonia ;  Phthisis ;      Pleurisy, 

Serous  inflammation  of  low   type.  Head-pain;    sudden 

Coma ;     cataract ;    Albuminuria,  Skin    disease,    boils, 
carbuncle,  psoriasis,  diarrhoea. 


ADDISON'S   DISEASE. 

Characterized  by  pigmentation  of  the  skin  ;  attacks  of  syncope 
and  extreme  debility  ;  Anaemia,  often  without  emaciation. 
Vomiting,  nausea,  or  epigastric  pain.  Discoloration  is 
a  bronzing  colour,  specially  marked  in  face,  hands,  neck, 
groins,  axillae,  penis,  scrotum  ;  areolae  very  dark  ;  buccal 
mucous  membrane  stained  ;  conjunctiva  always  free. 
Tendency  to  advance  to  death  by  asthenia.  Sometimes 
termination  is  sudden. 


30  CLIXICAL   MEDICINE   AND    CASE-TAKING. 


PURPURA. 

Skin. — Description :  Hseniorrliages  into  skin  may  occur  in  semTy, 

typhus,    measles,    variola,    or   from   injury.      Ecchymoses 

occur  on  forehead  and  under  conjunctiva  from  asphyxia  as 

*    in  epilepsy,  if  stage  of  tonic  spasm  is  prolonged,  and  after 

severe  paroxysms  of  hooping-cough. 

It  comes  out  in  successive  crops  in  aggi'egations  of  spots.  Note 
their  size,  situation  ;  whether  separate  or  confluent.  They 
do  not  fade  on  pressure,  do  not  enlarge  ;  but  others  may 
occui'  near  those  first  produced,  and  become  confluent  with 
them  ;  they  soon  absorb,  undergoing  changes  like  a  bruise. 
Some  fade,  while  others  appear.  They  occur  mostly  in 
dependent  parts,  and  are  apt  to  occur  in  the  legs  in  cardiac 
or  other  obstruction. 

The  spots  may  be  small,  "petechia,"  or  elongated  patches, 
"vibices,"  or  in  irregular  patches,  "ecchymoses." 
The  colour  is  violet,  purple,  or  blackish.  At  first  the 
margins  are  abnipt,  but  these  soon  fade.  Rarely  the  cuticle 
is  raised,  forming  "blebs."  Development  of  spots 
favoured  by  standing. 

Causation. — Hepatic  disease  ;  rheumatism  ;  syphilis  ;  heart 
disease  ;     any   debilitating   conditions ;     too   restricted   a 

diet. 

Not  uncommon  in  old  age,  and  accompanying  insanity. 

Look  for  htemon'hages  of  gastro-intestinal  canal.  Albuminuria 
and  signs  of  heart  disease  :  albumen  may  be  temporary. 
See  Heart  and  state  of  Vessels.  General  condition  of 
lassitude,  with  pain  in  limbs  and  joints. 


GENERAL  DISEASES — CLASS   II.  31 


DEVELOPMENTAL    DEFECTS. 

Head,. — Ill-shapen  ;  narrow,  prow-shaped  forehead  ;  hyper-ossi- 
fication in  various  parts.  It  may  be  too  large  or  too  small. 
lU-shapen  in  the  anterior  or  posterior  segments.  Forehead 
overhanging. 

Face. — Hare-lip  ;  epicanthic  folds  in  excess. 

Mouth. — Cleft  palate  and  uvula. 

Eyes. — Coloboma  of  iris  or  choroid,  i.e.,  a  deficiency  or  cleft ; 
mall-shaped  eyeball. 

Ea.rs. — Asymmetry  ;  one  or  both  may  be  more  or  less  rudi- 
mentary ;  helix  partly  unrolled,  with  rudiment  of  third 
lobe  ;  frequently  are  deformed  with  ichthyosis. 

Skin. — Ichthyosis  ;  hair  in  excess  on  forehead,  arms,  back  in 
children;  eyelashes  too  long  ;  fine  or  coarse. 

Fingers. — "Webbed;  supernumerary  fingers  or  two  thumbs,  etc.  ; 
inspect  feet  and  toes. 

Heart. — See  Congenital  Defects. 

Special  abnormalities.  —  Patency  of  abdominal  rings  ,  non- 
descent  of  testicle ;  long  prepuce ;  imperforate  anus  ; 
nsevus. 


32  CLINICAL   MEDICINE   AND   CASE-TAKING. 


SENILE   DEGENERATION. 

General  condition.  —  Nutrition ;  atrophy,  or  fatty  growth. 
Goitre  occasionally.  W.  =  .  Skin,  hair,  colour  ;  abun- 
dance.    Involution  of  generative  sj^stem. 


Locomotor  system. — Power  to  move  about;   state  of  joints; 
power  to  walk. 


Nervous  system. — Look  for  tremors    and   Paralysis   Agitans. 
Sleep  ;  pains ;  mental  power  ;  memory  ;  neuralgia. 


Eyes. — Arcus  senilis  ;  cataract ;  presbyopia  ;  hearing  and  special 
senses. 

Vascular  system. — State  of  Vessels;    heart-force.      Look  for 
varicose  veins  ;  purpura. 


Respiratory    system.  —  Emphysema ;     dyspnoea    on    exertion 
(cardiac). 


Digestive  system. — Teeth,  gums,  jaw ;  feeble  digestion  ;  flatu- 
lence, constipation. 


Urinary.  — Albumen. 


GENERAL   DISEASES — CLASS    II.  33 


SENILE  DEGENERATION. 


Sjjecial  degenerative  and  2Mthological  tendencies. — The  degene- 
ration may  be  simply  atrophy,  the  skin  becoming  wrinkled, 
or  there  may  be  fatty  growth  generally  under  skin.  Skin 
loses  elasticity,  becomes  wrinkled  and  pigmented  ;  it  loses 
transparency  and  brilliancy.  Hair  grows  on  chin  in  old 
women  ;  cancer. 


Nervous    system.  —  Brain    may   be    perfectly   sound   with   an 
atrophied  body. 


Prognosis  as  to  life. — Soundness  of  the  organs.  The  degree  of 
senility  not  being  greater  than  the  age  of  patient  indicates. 
Longevity  is  often  inherited.  Adaptation  of  patient's  life 
to  state  of  his  body. 


34  CLINICAL   MEDICINE   AND   CASE-TAKING. 

ARTHRITIC  DISEASES. 
ARTHRITIS. 

Note  pain,  tenderness,  swelling,  lieat,  redness,  effusion  in  joints, 
periarthritis.  Deposits  or  enlargement  of  ends  of  bones  or 
out-growth  therefrom.  Position  of  joints  ;  mobility  or 
anchylosis.     P.  =      ;  T.  =      ;  R.  =     . 


Look  for  signs  of  Rheumatism  and  its  complications  ^Gonor- 
rhcEal  Rheumatism ;  Gout  and  its  history  ;  Rheumatoid 
Arthritis,  especially  when  the  arthritis  has  a  chronic  course 
with  much  stiffness  and  but  little  fever. 


Tabulate  the  joints  affected,  indicating  the  condition  of  each 
— "effusion,"  "swollen  and  painful,"  "tender  and 
red,"  etc. 


RHEUMATOID    ARTHRITIS. 

Joints. — Arthritis  may  be  acute  or  subacute.  There  may  be 
effusion,  or  only  stiffness  and  pulpy  feeling  on  manipula- 
tion. The  hand,  when  made  into  fist  and  squeezed,  is 
tender  if  finger  joints  are  affected.  Enumerate  joints 
affected  ;  it  may  attack  temporo-maxillary  articulation,  or 
stiffen  cervical  spine.  Every  joint  in  the  body  may  be 
anchylosed.     Dislocation  of  affected  joints  may  occur. 

Causation. — Debilitating  causes,  haemorrhages,  mental  depres- 
sion, starvation ,  dampness,  and  possibly  heredity.  It  may 
occui"  at  any  age. 


ARTHRITIC   DISEASES. 


35 


ARTHRITIS. 

JOINTS. 

EIGHT. 

I 

Shoulder.  — 

Shoulder. — 

Elhow. — 

Elbow.— 

Wrist.— 

Wrist.— 

LEFT. 


Hand. — Note     separately    the      Hand. — 
metaearpo-phalangeal  joints 
and  internodes. 

Hip. —  Hi}). — 

Ankle. —  Ankle.-^ 

Foot. — Specially    note     meta-      Foot. — 
carpo-phalangeal    joint     of 
great  toe. 

Temporo- maxillary  and  vertebral  joints. 


RHEUMATOID  ARTHRITIS. 

Small  joints  commonly  first  affected,  but  large  joints  may  be 
equally  attacked.  The  attacks  last  longer,  are  less  severe  ; 
less  pyrexia  and  constitutional  disturbance  than  with  Gout 
and  acute  Rheumatism;  more  thickening  left,  with 
deformity  of  joints.  No  deposits  of  urate  of  soda  ;  no 
sweating.  More  commonly  commences  in  fingers  than 
toes,  and  not  with  a  sudden  short  attack  of  single  joints. 

Complications  and  accompaniments. — Any  organic  disease. 
Anaemia ;  Neuralgia. 


36  CLINICAL   MEDICINE   AND    CASE-TAKING. 


RHEUMATISM. 

Histoiy  of  rheumatism  ;  heart  disease  ;  chorea  in  family  and  in 
collateral  relations.     Previous  attacks  in  patient. 

Present  condition. — General  signs  of  Fever.  P.  =  ;  T.  =  ; 
R.  =  .  Skin  moist,  sweating,  sudamina.  Note  any 
erythema. 

Joints. — Whether  tender  or  painful  on  movement  ;  swollen  with 
effusion,  with  or  without  cutaneous  redness.  Enumerate 
the  joints  affected,  specially  noting  whether  large  or  small 
joints  are  mostly  affected. 

Vascular  system. — Development  of  cardiac  bruits  from  valvular 
disease  ;  pericarditis,  with  or  without  effusion.  Always 
map  out  area  of  cardiac   dulness.     Pulse,  regularity,  etc. 

Eesjnra.tor]/  system. — Pleurisy,  single  or  double  ;  extensive 
effusion  common.  Pneumonia,  usually  at  base  ;  it  may 
occur  without  special  acute  symptoms. 

Nervous  system. — Rheumatism  may  alternate  with  chorea,  one 
follo\^ing  the  other,  near  or  at  distant  intervals.  Occasion- 
ally delirium.     Sleep. 

Urine. — Usually  a  deposit  of  pink  lithates  during  fever.  Rarely 
a  trace  of  albumen. 

IthcumaMsm  in  children. — Symptoms  often  less  severe  than  in 
adults  ;  less  pain,  but  little  fever  ;  skin  often  dry  ;  great 
tendency  to  heart  disease,  even  when  able  to  walk  about  ; 
often  thought  to  be  "growing  pains  ;"  duration  of  fever  a 
very  few  days,  or  it  may  be  absent. 

Noddies  wwdiQY  skin  not  uncommon,  even  without  arthritis  or 
pain  ;  most  common  on  prominences  of  bones  or  tendons, 
about  elbow,  knee,  ankle,  spine.  They  are  usually 
accompanied  by  progressive  heart  disease. 

Minor  sym,2ytoms.' — Liability  to  swollen  joints  on  over-exertion  ; 
stiff  neck  ;  effusion  in  sheaths  of  tendons. 

Purpura. — Great  liability  of  serous  inflammations  without 
arthritis.     Erythema. 


ARTHRITIC   DISEASES.  ,  37 


RHEUMATISM. 

A  febrile  disease,  characterized  by  pyrexia  and  arthritis  with 
effusion,  the  inflammation  changing  from  joint  to  joint  and 
attended  with  great  pain.  Skin  moist,  often  sweating  ; 
this  may  be  excessive  and  produce  miliaria.  Great  tendency 
to  serous  inflammations  attended  with  great  effusion, 
usually  quickly  absorbed  and  not  leading  to  suppuration. 
Tendency  of  all  these  conditions  to  relapse  after  convales- 
cence.    Subacute  attacks  often  succeed  the  acute. 


In  children  pain  and  fever  often  slight,  but  still  tendency  to 
heart  damage  very  great. 


Nodules. — Small  masses  of  fibrous  growth  from  size  of  a  pin's 
head  to  an  almond,  often  felt  better  than  seen  ;  painless, 
usually  movable. 


Complications. — Inflammatory  conditions  ;  endocarditis  ;  Peri- 
carditis; Pleurisy;  Pneumonia;  Bronchitis.  Relapses  of 
fever  and  arthritis.  Erythema.  Hyperpyrexia  ;  Delirium  ; 
Chorea.     Albuminuria  occasionally. 


Tonsillitis  is  frequent  at  the  onset  with  fever,  or  it  may  precede 
it  by  a  week  or  two.    At  same  time  there  may  be  stiff"  neck. 


Causation. — Exposure  to  cold  and  wet.     Inherited   tendency. 
Tendency  to  recurrence,  especially  in  early  years. 


Exciting  causes. — Exposure,  over  fatigue.      Xote  recent    ante- 
cedents ;   scarlet  fever,  tonsillitis,  pharyngitis. 


38  CLINICAL   MEDICINE   AND    CASE-TAKING. 


GONORRHCEAL    RHEUMATISM:. 

Joints. — Wrist  and  knee  affected  by  preference.  Pain  and 
effusion  ;  much  stiffness,  often  causing  a  considerable 
amount  of  anchylosis,  No  tendencj^  to  suppm-ation,  but 
infilti'ation  and  thickening  around  joint. 

Generative  system. — Muco-purulent  or  gleety  discharge  from 
urethra. 


GOUT. 

Joints. — Enumerate  joints  affected.  Note  periarthritic  inflam- 
mation and  infiltration,  deposit  of  concretion,  or  thickening 
of  bones.  Examine  bursse  for  tophi.  Take  the  history  of 
previous  joint  affections.     See  Arthritis. 

Vascular  system. — When  gout  has  lasted  many  years  the 
vascular  system  often  degenerates  ;  Heart  becomes  dilated 
and  hypertrophied,  especially  with  Granular  Kidneys. 
Pulse,  force  and  tension. 

Digestive  system. — General  signs.  These  functions  are  often 
disturbed.  Teeth  much  gi'ound.  Liver  disease  common. 
Enquire  for  piles. 

Urine. — Often  albuminous  with  signs  of  chronic  Bright's 
disease.     Amount  of  TJric  Acid  deficient. 


AETHRITIC   DISEASES.  39 


GONORRHEAL  RHEUMATISM. 


Seldom  seen  in  females.  The  disease  runs  its  course  through 
weeks  or  months.  After  slightly  affecting  many  joints  it 
becomes  confined  to  one  or  two.  No  great  pyrexia  ;  but 
little  tendency  to  inflammation  of  internal  organs. 


GOUT. 

An  acute  attack  usually  commences  in  early  morning  in  one 
great  toe.  Severe  pain,  followed  by  swelling  around  the 
joint ;  local  oedema ;  skin  red  and  glazed,  exquisitely  tender. 
Attacks  tend  to  recur  at  shorter  intervals.  Tophi  or 
concretions  of  urate  of  soda  may  form  around  joints,  in 
bursse,  or  in  the  external  ears. 

Causation. — Most  common  in  males  at  middle  life.  Hereditary 
tendency  marked.  Habits  of  intemperance  ;  exposure  to 
weather.  Plumbism.  Any  depressing  circumstances  or 
injury  may  excite  an  attack. 

Complications  aind  accompaniments. — Chronic  Bright's  Disease. 
Heart  changes  and  Disease  of  Vessels.  Skin  affections  ; 
psoriasis,  eczema.  Diabetes.  Liver  disease.  Thrombus  in 
veins.     Tophi  may  discharge,  forming  sinuses. 


40  CLINICAL   MEDICINE   AND    CASE-TAKING. 

DISEASES  OF  THE  NEEYOUS  SYSTE:M 

NERVOUS   SYSTEM. 

General  conditions. — Intelligence  ;  Speech  ;  Sleep  ;  Head- 
pain  ;  Vertigo  ;  Coma  ;  Vomiting  ;  Paralysis  ;  Convul- 
sion ;  Spasm  ;  Tremor  ;  Rhythmical  Muscular  Move- 
ments ;  Delirium. 

INTELLIGENCE. — Giving  good  clear  answers  to  questions. 
Memory  :  Memory  for  past  events,  or  those  of  recent 
occuiTence ;  power  to  perform  easy  calculations.  The 
face  may  temporarily  or  permanently  lose  the  expression  of 
intelligence. 

SPEECH. — Stammering.  Slow,  jerky.  Using  inarticulate 
sounds  only.     Mute.     Aphasia. 

SLEEP. — Easily  falling  asleep  ;  sleeping  soundly  and  waking 
up  refreshed  in  the  morning.  Wakeful ;  disturbed  by 
dreams  ;  remembering  dreams.  Insomnia,  i.e. ,  loss  of  sleep. 
Raving  at  night.     Somnambulism.     Tooth  gi'inding. 

HEAD-PAIN. — 1 .  Its  situation,  whether  general  or  local. 

2.  Its    characters — heavy,    dull,    aching,    throbbing,    shoot- 

ing, darting,  sense  of  fulness.  Whether  constant,  inter- 
mittent, recurrent,  or  periodical.  Its  intensity  and 
variability. 

3.  Effects  of  movement  and  change  of  position,  of  light  and 

sounds,  etc. 

4.  Its  mode  of  onset.     If  previous  attacks,  note  periodicity. 

5.  If  accompanied  by  soreness  or  tenderness   at  particular 

spots,  see  Neuralgia. 

6.  Look  to  state  of  Special  Senses,  especially  Sight ;  Inquire 

for  dysesthesia  of  sight. 

7.  If  accompanied  by  Vomiting,  note  its  relation  to  pain. 

8.  Look  for  signs  of  Brain  Disease,  Convulsions,  Paralysis, 

Hysteria,  Condition  of  Sensation.  Examine  Optic 
Discs.     Look  for  Neuralgia. 

9.  Examine  urine  for  sugar  and  albumen. 
10.  Character  of  pulse  ;  temperature. 

History  of  neurosis  in  individual  or  family.  History  of 
phthisis  or  strumous  affections. 


DISEASES   OF   THE   XERVOUS   SYSTEM.  41 

NERVOUS     SYSTEM. 

Oeneral  conditions. — Note  all  departures  from  the  physiological 
condition.  The  muscular  power  should  be  such  as  to 
enable  ordinary  work  to  be  performed. 

INTELLIGENCE  may  be  naturally  dull  or  mental  power  may 
be  lost  from  disease,  e.g.,  senile  decay,  dementia,  general 
paralysis,  epilepsy.  Mental  delusions  may  arise  in  sane 
people.  Intelligence  is  proportioned  to  age,  education, 
and  surroundings.     Ask  as  to  school- work  in  children. 

SPEECH. — Aphasia  =  loss  of  faculty  to  speak  words,  though 
he  can  recognize  them  when  written  or  spoken. 

Amnesia  —  loss  of  faculty  for  the  memory  of  words,  but 
can  repeat  them  if  suggested  to  him. 

SLEEP. — Restless  tendency  to  turn  the  body  may  prevent 
sleep  even  if  drowsiness  is  present ;  frequent  in  Alcoholism, 
Insomnia  may  be  caused  by  heart  disease  or  over  mental 
exertion.  Muscular  tmtching  and  cramps  not  uncommon 
from  fatigue.     Pain  may  prevent  sleep. 

HEAD-PAIN. — The  first  thing  to  decide  is  whether  the  case 
be  one  of  organic  or  functional  disease  ;  in  the  latter  case, 
the  attacks,  when  recur^-ent,  are  commonly  spoken  of  as 
headaches. 

HEADACHE  may  be  pericranial,  frontal,  occipital,  or  diffused, 
or  bilateral.  Headaches  may  recur  periodically  ;  in  women 
frequently  at  the  menstrual  period.  After  an  attack  there 
is  a  certain  amount  of  immunity.  Attacks  may  be  excited 
by  over-work,  sleeplessness,  want  of  food,  errors  of  diet, 
constipation,  etc.  With  the  attacks  disorders  of  sight  are 
common :  sparks,  coloured  stars,  zig-zags  Avith  coloured 
bright  margins;  hemiopia  (seeing  only  half  of  any  object 
looked  at).  Other  senses  may  be  disordered.  Vomiting 
frequently  terminates  the  attack.  Accompanying  the 
attacks,  or  alternating  with  them,  may  be  much  mental 
depression,  mental  weakness,  and  perverted  ideas  of  things. 
Such  recurrent  headaches  are  common  during  pregnancy. 
Such  attacks,  accompanied  by  vomiting  and  coloured 
vision,  are  often  spoken  of  as  "  bilious  attacks." 

History. — Look  for  signs  of  Meningitis  and  Brain  Disease. 


42  CLINICAL   MEDICINE   AND    CASE-TAKING, 

VERTIGO. 

I.  Feeling   of  giddiness   experienced   by    the   patient,   objects 

appearing  stationary. 

II.  External  objects    appear   to  move,    e.g. ,    up    and   down, 
horizontally,  approaching  and  receding. 

Vertigo    may    be    increased   or  relieved    by    movement    and 

position. 
Test  hearing  and  sight.     Examine  for  diplopia.     Look  for  signs 

of  Brain  Disease.     Anaemia.   Examine  Vascular  System. 

Urine. 

COMA. 

History  ;  onset ;  previous  signs  of  Brain  Disease ;  Convulsions  ; 

Vomiting. 
Causation. — 1.  Injury  to  head. 

2.  Examine  urine  generally,  and  for  sugar  and  albumen  ;  also 

for  alcohol  and  poisons. 

3.  Cerebral   Heemorrhage.     See   signs   of  Bright' s   Disease. 

Vascular  Degeneration. 

4.  Coma  sequent  to  Convulsion. 

5.  Coma  may  occur  during  fevers. 

6.  Meningitis  and  coarse  brain  disease. 

7.  Heart  failure.     Examine  pulse  and  heart's  sounds. 

8.  Delirium  frequently  ends  in  coma. 

9.  Alcoholism  and  poisons. 

Circulation. — Xote  pulse,  small  and  soft  in  syncope,  often  hard 

in  ursemia.     First  sound  in  heart  failure. 
LooJc  for  signs   of  Brain  Disease.     State  of  Intelligence  and 

Sensation.     Test  poAver    to   perform    certain    acts,     e.g., 

protrude     tongue,     swallow     food,     move     fingers,     etc. 

Condition    of    sphincters.      Note     condition     of     sleep. 

Delirium.     Subsultus  tendinum.     Position  of  body,   e.g., 

dorsal     decubitus.      Character     of   respiration,     whether 

stertorous. 
Examine  for  signs  of  Brain  Disease  and  Paralysis.     Examine 

urine  ;    lungs  ;   heart,    its   strength    and  sounds  ;   pulse  ; 

condition  of  arteries.     Smell  breath  for  alcohol.     (Edema. 

Temperature.      Action  of  sphincters.     Eyes  :  strabismus  ; 

Pupils.     Ophthalmoscope.     Reflexes. 


DISEASES^    OF   THE   NEEYOUS    SYSTEM.  43 

VERTIGO. 

May  occur  during  sleep  or  on  waking.  It  is  common  at 
climacteric  period  with  degeneration  of  vessels, 
Emphysema,  Bright' s  Disease.  Vertigo  may  be  due  to 
diplopia  dependent  upon  weakness  of  an  ocular  muscle 
or  to  some  error  of  refraction  as  hypermetropia. 
Meniere's  disease  of  ear  ;  Alcoholism  ;  excessive  smoking  ; 
mental  or  physical  exhaustion ;  dyspepsia  ;  anaemia; 
heart  disease  ;  exposure  to  the  sun.  It  may  accompany 
simple  recurrent  Headaches . 

COMA. 

History.     Coma  may    result   from  old-standing  brain  disease. 

There    may   be  history   of    chronic    disease     capable    of 

producing  coma. 

Causation. — 1.  Injury  may  produce  compression  of  the  brain. 

Collapse  ;  shock  ;  syncope. 

2.  See   Uraemia.     In    Diabetes    glycosuria    may    disappear 

before  coma  sets  in. 
a.  Extensive  cerebral  hsemorrhage   may   cause   deep   coma. 
Haemorrhage   into  pons  causes   universal   powerlessness 
and  contracted  pupils,  resembling  opium  poisoning. 

4.  Any  severe  exhaustion  may  cause  coma. 

5.  Exposure  to  great  heat,  as  summer  sun. 

6.  Almost  any  brain  disease  may  end  in  coma. 

7.  Arterial    Disease    may  lead  to    cerebral    haemorrhage  ; 

heart  disease  to  Embolism. 

8.  This  is  a  great  danger  in  fevers. 

Look  for — Coma  may  be  partial  or  complete,  constant  or 
remittent.  Signs  of  motor  power  may  be  partially 
or  wholly  lost.  It  may  be  a  sign  of  the  Typhoid  state, 
with  delirium ;  then  the  pulse  is  usually  very  soft. 
"Wandering  at  night  in  febrile  diseases  may  pass  on  into 
Delirium  and  coma.  The  lungs  are  usually  congested,  with 
pulmonary  oedema  or  hypostatic  pneumonia. 

ExamiTie  for  Alcoholism;  smell  breath  and  test  urine.  The 
vomits  or  washings  of  the  stomach  may  be  smelt  and 
tested  for  poisons — opium,  alcohol,  hydrocyanic  acid. 
Urine  may  be  obtained  by  the  catheter.  Stomach-pump 
may  be  used  in  poisoning  cases.  Avoid  mistaking  brain 
disease  for  poisoning. 


44  CLINICAL   MEDICINE   AND    CASE-TAKING. 


VOMITING. 

Describe  vomits ;  containing  undigested  food,  frothy  like 
yeast  ;  look  for  sarcinse  ;  watery  ;  smell  ;  containing  blood 
or  bile. 

See  State  of  Tongue  and  bowels  ;  Abdominal  Pain  ;  signs  of 
dyspepsia. 

Look  for  reflex  causes,  e.^., pregnancy,  Ovarian  Tumour,  disease 
of  liver,  Gall-stones ;  Renal  Calculus.     Examine  urine. 

Causatiaa. — Stomach  disease  or  derangement.  ffisophageal 
obstruction.  Obstruction  of  Bowels.  Poisons.  Alcoholism. 
Uraemia.  Hepatic  disease.  Pelvic  disease.  Pregnancy. 
Ovarian  disease.  Addison's  Disease.  Brain  Disease  or 
disturbance.     Migraine. 


DELIRIUM. 

Its  characters  ;  if  attended  with  illusions  and  purposeless 
muscular  movements,  e.g.,  subsultus  tendinum,  picking  of 
bed-clothes,  etc.  Test  consciousness  by  speaking  to 
patient  and  requiring  an  ansAver  to  a  question,  or  that  he 
shall  protrude  his  tongue,  etc. 

Causation. — Plumbism,  Alcoholism,  and  such  causes  as  may 
produce  Coma.     Belladonna.     Camphor. 


TYPHOID     STATE. 

Asthenia  or  adynamia.  Temperature  not  high.  Tongue 
tends  to  dryness,  with  crusting  and  formation  of  sordes  on 
teeth  and  gums  ;  lips  cracked  and  dry  ;  deglutition  difficult. 
Pulse  very  soft,  compressible,  dicrotous,  irregular.  Heart's 
action  weak  ;  first  sound  hardly  heard.  Tendency 
to  pulmonar}^  congestion,  cedema,  and  hypostatic 
pneumonia. 

Drowsiness  ;  Delirium  ;  Coma ;  subsultus  tendinum  ;  picking 
bed-clothes.  Paralysis  of  sphincters  or  retention  of  urine. 
Dorsal  decubitus  complete. 


DISEASES    OF   THE   NERYOUS   SYSTEM.  45 

VOMITING. 

If  of  cerebral  origin  it  is — 1.   Purposeless,   not  specially  after 
taking  food,  and  not  relieving  symptoms. 

2.  Tongue  clean  ;  no  special  signs  of  Digestive  Disturbance. 

3.  General  absence  of  premonitory  symptoms  or  nausea  before 

vomiting  ;   contents  of  stomach  ejected  easily  without 
retching  or  much  effort. 

4.  Yomiting  frequently  aiTested  by  the  horizontal  position, 

recurring  on  becoming  erect. 

5.  Concomitant  signs  of  disturbance  of  the  Nervous  System 

or  signs  of  Brain  Disease. 
If  vomiting  appear  to  be  of  cerebral  origin  use  Ophthalmoscope. 
Take  temperature  ;  look  for  other  signs  of  Brain  Disease. 
Intermittent   pulse   is   an   early   sigu    of    Meningitis    in 
children. 

DELIRIUM. 

May  be  active  ;  violent ;  low  muttering.  It  usually  commences 
at  night  with  talking  and  wandering  of  the  mind.  AVhen 
moderate  in  degree  temporary  consciousness  may  be 
restored  by  speaking  loudly  and  clearly,  Is  usual  in  the 
course  of  fevers.  It  may  be  due  to  simple  exhaustion  ;  as 
from  hsemorrhage  after  labour,  etc. 


TYPHOID  STATE. 

A  prostrated  condition,  nervous  symptoms,  heart  failure.  An 
unfavourable  termination  of  Delirium,  Coma,  delirium 
tremens,  and  acute  febrile  diseases.  Note  at  each  observa- 
tion strength  of  heart  sounds,  force  of  pulse,  and  the  mani- 
festation of  any  further  nervous  symptoms.  Dorsal  decu- 
bitus is  usually  complete,  i.  e. ,  the  patient  lies  flat  in  the 
trough  of  the  bed  ;  muscular  power  is  prostrated.  If  pro- 
longed, bed-sore  may  form.  Albuminuria  and  hypostatic 
pneumonia  frequently  coincident. 


46  CLINICAL   MEDICINE   AND    CASE-TAKING. 

PARALYSIS. 

See  Hemiplegia ;  Palsy  of  Cranial  Nerves ;  Minor  Paralyses. 
Test  Motor  Power. 

See  signs  of  Brain  Disease ;  signs  of  Disease  of  Spinal  Cord. 

View  the  part  paralysed,  and  examine  as  to  Motor  Power. 
Note  the  parts  paralysed  and  the  muscles  affected,  stating 
whether  the  fine  and  general  movements  of  the  limb  are 
wholly  lost.  Kote  state  of  nutrition  of  the  part,  contrac- 
tions, rigidity,  etc.  Test  reflex  action  by  tickling, 
pricking,  etc.  See  Sensation.  Electric  Tests.  Examine 
Optic  Discs.  Look  for  signs  of  Syphilis.  Vascular 
Degeneration. 

ELECTRIC   TESTS. 

If  one  muscle  contract  to  a  lesser  force  of  the  cuiTent  than 
another,  it  is  said  to  be  more  irritable,  To  ascertain  the 
irritability  of  a  muscle  reduce  the  strength  of  the  current  to 
the  lowest  point  at  which  it  will  produce  action.  A  full 
power  of  current  simply  shows  the  strength  of  the  muscle. 
If  in  hemiplegia  there  be  a  well-marked  difference  in  the 
reaction  of  the  two  sides  the  paralysis  is  not  feigned. 
Diminished  contractility  may  be  due  to  disease  of  brain, 
cord,  motor  nerve,  morbid  condition  of  the  muscle. 

The  faradaic  current  may  be  applied  over  the  muscle  to  be 
tested,  or  the  galvanic  current  to  the  nerve  supplying  it. 

Loss  of  electric  contractility  is  a  sui'e  sign  of  disease. 
Faradization  is  sometimes  useful  to  prove  the  presence  of 
muscle  in  a  fat  limb  in  which  it  is  suspected  that  tissue 
is  wasted. 

Functional  aphonia  may  be  from  hysteria  or  exhaustion.  Some- 
times the  fauces,  palate,  and  pharynx  are  anaesthetic. 
Laryngoscope  shows  healthy,  motionless,  white  true  cords, 
and  a  larynx  otherwise  healthy. 

Histoi'y  — Often  sets  in  suddenly.     Liable  to  relapses. 

Look  for  Hysteria,  Phthisis.     Signs  of  mediastinal  pressure. 


DISEASES    OF   THE   NERVOUS   SYSTEM. 


47 


PARALYSIS. 

Paralysis  may  depend  upon  disease  of  nerves  or  nerve-centres, 
or  may  be  only  Functional  Paralysis.  "When  a  muscle  is 
paralysed,  it  usually  atroj)hies  in  a  short  time,  and  on 
regaining  strength  regains  its  nutrition.  In  pseudo- 
hypertrophic Paralysis,  the  flexor  muscles  of  the  lower 
extremities  become  weak,  but  greatly  enlarged. 
In  paraplegia,  see  Spinal  Cord  Disease. 

Paralysed  muscles  often  become  rigid,  e.g.,  hemiplegia, 
Infantile  Paralysis.  General  muscular  weakness,  not 
dependent  on  simple  debility  and  not  secondary  to  disease 
of  viscera,  is  seen  in  General  Paralysis  and  Diphtheritic 
Paralysis.     See  Minor  Paralyses. 

FUNCTIONAL.  ORGANIC. 

Age  and  sex. — Most  frequent  at  Most  common  in  degene- 

onset  of  puberty  and  climac-       ration  ;  sexes  more   equally 
teric  period  ;  almost  confined 
to  females. 
Hysteria. — Present  more  or  less. 
No  signs  of  organic  disease. 


^  trophy  of  palsied  iKtrt.  — Palsied 
part  well  nourished.  No 
bed-sore. 

Sensation. — May  be  lost,  hy- 
persesthetic,  or  perverted. 

Reflex  action. — Not  obliterated. 

Electric  tests. — Reaction  readi- 
ly obtained. 

Palsy  of  Cranial  Nerves. — Not 
seen. 

Aphonia. — Common  ;  may  be 
the  only  palsy. 

Part  paralysed.  —  Frequent 
change.  Often  partial  of  one 
limb  or  part.  Sphincters  not 
paralysed.  Urine  often  re- 
tained. 


affected. 

No  signs  of  Hysteria  of 
Epilepsy.  Disease  of  heart, 
kidneys,  etc. 

Atrophy  follows  paralysis. 
Sacral  bed-sore  frequent. 

If  lost  temporarily,  usually 
returns  before  motor  power. 
In  very  many  cases  lost. 
Lost  in  disease  of  cord. 

Common ;  specially  of  face 
and  tongue. 

Rare  from  organic  nerve 
disease.  See  Aphasia  in 
right  hemiplegia. 

No  changes  without  fresh 
lesion.  May  be  perma- 
nently rigid,  with  coldness 
and  tendency  to  slight 
ojdema. 


48 


CLINICAL   MEDICINE   AND    CASE-TAKING. 


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50  CLINICAL   MEDICINE   AND    CASE-TAKINa. 


CONVULSION. 

Par oxy 3771. — Note  the  order,  progress,  and  kind  of  spasm  ; 
whether  mostly  Tonic  or  Clonic  Spasm,  Commencement, 
whether  general  or  local ;  commencing  on  one  side,  e.g.,  one 
hand  or  finger.  Note  suddenness  of  onset,  whether 
attended  with  asphyxia  and  marked  cyanosis  ;  its 
duration.  Face  pale  or  flushed ;  fulness  of  veins ; 
whether  distortion  of  face  ;  head  retracted.  Eyes  :  their 
position  ;  strabismus ;  state  of  Pupils.  Condition  of 
consciousness. 

Premonitory  symptoms. — Aura  Epileptica;  muscular  twitches; 
dilatation  of  pupils. 

Causation. — Brain  Disease  ;  Rickets ;  Syphilis  ;  Bright's 
Disease  ;  Epilepsy;  Hysteria.  Acute  diseases — (1)  Cerebral ; 

(2)  Febrile ;  (3)  Exanthemata ;  (4)  Pulmonary.  Reflex 
exciting  causes,  e.g.,  indigestion,  w^orms,  teething,  ear 
disease.     Examine  heart,  urine,  temperature. 

Sequelce. — Paralysis ;  amaurosis  ;  strabismus ;  defect  of  speech ; 
mental  disturbance  ;  mania  ;  drowsiness  ;  sleep  ;  Coma. 

SPASM. 

1.  Tonic  Spasm  =  continuous  muscular  contraction  during   a 

longer  or  shorter  interval. 

2.  Clonic    Spasm  =  alternate    contraction    and    relaxation    of 

muscles. 

racial  Spasm  is  usually  one-sided  only.  The  successive  clonic 
spasms  are  of  equal  extent  and  severity,  so  that  successive 
grimaces  resemble  one  another.  In  many  cases  it  is 
chronic  in  duration  and  unaccompanied  by  other  spasms. 
In  these  particulars  it  differs  from  Chorea. 

Writers'  Cramp. — On  attempting  to  wTite,  the  muscles 
ordinarily  used  in  the  act  are  thrown  into  a  state  of  tonic 
spasm  ;  this  subsides  on  discontinuing  the  act  of  WTiting. 
Other  dissimilar  acts  may  be  performed  without  spasm. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  51 


CONVULSION. 

Paroxysm. — Usually  commences  wdth  tonic  spasm  and  pallor 
or  cyanosis,  followed  by  clonic  spasms.  One  side  or  one 
limb  may  be  primarily  or  chiefly  affected ;  then,  occasionally, 
the  eyes  and  head  turn  to  that  side,  and  there  may  be  a 
few  one-sided  jerks  of  the  head.     Pupils  usually  dilated. 

Premonitory  sym,ptoms. — In  children,  frequently,  fist  is  clenched, 
with  thumb  turned  in.  Laryngismus  may  precede 
convulsion. 

Causation. — In  children  convulsions  are  very  easily  produced 
by  slight  causes.  Ill-feeding,  teething,  worms,  and 
Rickets  very  common  predisposing  causes.  Pyrexia  may 
be  due  to  an  acute  disease  or  to  continued  tonic  spasm. 
Urine  may  be  albuminous  from  Blight's  Disease,  or  may 
contain  albumen  or  sugar  consequent  upon  the  convulsion. 

Sequelce. — Convulsions  may  be  symptomatic  of  brain  disease, 
which  may  subsequently  advance. 


SPASM. 

Tonic  Spasm  is  frequently  attended  by  pain,  and  may  be 
preceded  by  hypersesthesia.  It  is  seen  in  the  first  stage 
of  an  Epileptic  convulsion  ;  trismus,  or  lock-jaw  ;  tetanus  ; 
spasmodic  talipes  ;  spasmodic  torticollis. 

Clonic  Spasm  may  be  increased  by  effort  or  mental  excite- 
ment, and  may  subside  during  sleep  and  under  chloroform, 
e.g.,  epilepsy.  It  causes  movement  or  displacement  of 
the  limb  or  part  affected.  It  is  seen  in  chorea  and 
muscular  tic. 

Causation. — Look  for  signs  of  Hysteria.  Reflex  exciting 
causes,  e.g.,  pregnancy,  intestinal  worms,  teething. 
Dyscrasise,  Ursemia,  fevers,  spinal  irritation,  and  menin- 
gitis.    Hydrophobia.     Hysteria.     Brain  Disease. 


52  CLINICAL   MEDICINE   AND    CASE-TAKING. 


LARYNGISMUS. 

Look  to  Nervous  System.  Convulsion.  General  convulsions 
often  follow.  It  may  occur  in  hysterical  women,  but  is 
most  common  in  infants.  Paroxysms  may  be  brought  on 
by  excitement  or  fatigue.  Look  for  Rickets,  teething, 
constipation.  There  may  be  tonic  contretction  of  muscles 
of  limbs. 


TREMOR. 

L  Tremor  absent  when  at  rest,  but  of  various  intensity  when 
executing  a  more  or  less  co-ordinated  movement,  e.g., 
raising  a  glass  of  water,  picking  up  a  pin. 

IL  Tremor  continuous  and  permanent.  Purposive  movements 
exaggerate  it,  but  it  does  not  disappear  on  repose. 

K'ote  the  sets  of  muscles  affected  ;  whether  head  is  moved  ; 
whether  muscles  supplied  by  Cranial  Motor  Nerves  are 
affected.  Test  Patellar  Tendon  Reflex,  Take  sample  of 
patient's  writing. 


RHYTHMICAL  MUSCULAR  MOVEMENTS. 

Athetosis  =  gliding  movements,  frequently  repeated  in  the 
same  order.  Generally  accompanies  epilepsy,  and  usually: 
hemiplegic  in  situation. 


DISEASES    OF   THE   NERVOUS   SYSTEM.  53 


LARYNGISMUS. 

Characterized  by  paroxysmal  convulsion  of  the  laryngeal 
muscles  and  noisy  inspiration  ;  no  specific  catarrh  or 
special  lung  trouble,  as  in  Hooping-cough.  Muscles  of 
chest  and  abdomen  may  be  involved.  Most  common  in 
young  boys,  and  on  waking  from  sleep.  It  may  become 
almost  continuous  crowing,  the  veins  being  distended  and 
face  distressed.     Child  rarely  dies  in  an  attack. 


TREMOR. 

In  Paralysis  Agitans,  tremor  continues  when  at  rest. 

In  Sclerosis,  ti'emor  is  increased  by  movement,  ceasing  during 
repose  ;  so  also  in  mercurial  tremor. 

In  paralysis  agitans,  the  face,  head,  and  cranial  nerves  usually 
escape. 

Sleep  arrests  ti'emor  temporarily.  Tremor  may  be  general, 
affecting  the  head,  or  not ;  it  may  be  localized  to 
a  limb.  Tremor  is  a  simple  vibratory  repetition  of 
purposeless  movements,  not  displacing  a  limb  greatly. 
Fine  movements  are  those  through  small  arcs. 

Muscular  tremor  is  a  characteristic  symptom  in  paralysis 
agitans.  Disseminated  sclerosis ;  Alcoholism ;  mercurial 
tremor  ;  General  Paralysis  of  the  Insane. 


RHYTHMICAL   MUSCULAR   MOVEMENTS. 

Athetosis  may  be  a  congenital  or  an  acquired  disease  ;  it  may 
be  hemiplegic  or  both-sided. 


54  CLINICAL   MEDICINE    AND    CASE-TAKING. 


MOTOR  POWER. 


Ability  to  stand,  -walk,  walk  up  stairs,  work,  etc.  State  some 
act  the  patient  can  or  cannot  perform ;  how  far  he  can  Avalk. 
Power  over  large  joints,  small  joints,  finer  movements  of 
fingers,  e.g.,  writing. 


Movements  of  upper  mid  lower  extremities. — Test  power  of 
simple  movement,  and  power  to  overcome  resistance. 
Test  movements  of  larger  joints  and  muscles  ;  and  power 
over  individual  digits. 


Movements  of  head  and  trunk. — Patient  lying  on  his  back,  let 
him  erect  trunk  -without  use  of  hands.     Examine  spine. 

Respiratory  movements. — Note  respiratory  rhythm  ;  movements, 
whether  principally  thoracic  or  diaphragmatic. 


Co-ordinaMon  of  the  limbs. — Gait  in  walking ;  walking  well 
and  firmly  with  head  erect  ;  also  walking  straight  with 
eyes  shut ;  walking  stiff,  one  joint  being  kept  immobile 
from  pain  ;  hip  movements  much  restrained  in  Sciatica. 
Circumducting  one  leg,  s\vinging  it  round,  not  moving  it 
forward  as  the  other,  seen  in  Hemiplegia.  Staggering, 
moving  trunk  over  place  where  the  legs  are.  Lifting  legs 
inordinately  high,  then  bringing  them  suddenly  down. 
Walk  with  eyes  shut.     Test  for  Muscular  Anaesthesia. 


DISEASES  OF   THE  NERVOUS   SYSTEM.  55 


MOTOR  POWER 


May  be  lessened  from  general  weakness  or  be  lost  in  one  or 
two  extremities  only,  or  in  a  certain  group  of  muscles. 
See  Paralysis. 


Movements  of  upper  and  lower  extremities. — Palsy  of  upper 
extremity,  if  of  cerebral  origin,  is  usually  accompanied  by 
weakening  of  lower  extremity.  Let  patient  move  limbs 
to  order  ;  lift  weights  ;  pick  up  a  pin,  etc. 


Movements  of  head  and  trunk. — Motor  power  over  spine  may  be 
lost  from  caries  of  spine.  Pseudo-hypertrophic  Paralysis. 
View  spine  ;  feel  for  curvatures. 


Respiratory  tnoxiements. — Cheyne's  respiration.  =  a  series  of 
respirations  hurried  and  deep  up  to  a  certain  point,  then 
subsiding  to  a  dead  pause. 


Go-ordination  of  the  limbs. — If  defective,  examine  joints. 
Sciatica.  Spasms.  Tremors.  Paraplegia.  Chorea.  In 
Paralysis  Agitans  there  is  a  tendency  to  propulsion  or 
retropulsion.  In  General  Paralysis,  stumbling  and 
staggering,  or  tottering.  In  Ataxy,  muscular  power  in 
the  legs  is  not  lost  ;  the  patient  may  walk,  feeling  the 
ground  with  a  stick.  In  Hemiplegia  the  patient  in 
walking  swings  round  the  leg,  and  then  keeping  it  stiff 
balances  the  trunk  upon  it. 


56  CLINICAL   MEDICINE   AND    CASE-TAKING. 


SENSATION. 

Objective  sensibility  (ascertained  by  examination). — Tactile 
sensibility  of  skin.  Examine  separately  the  flexor  and 
extensor  surfaces,  face,  trunk.  Test  tbe  least  distance  at 
Avbich  two  points  can  be  distinguished  in  various  regions. 
Sensibility  to  heat  and  cold.  Apply  to  various  parts  two 
test  tubes,  one  containing  hot  water,  the  other  cold.  Or 
apply  a  hot  and  cold  sponge  alternately. 

Subjective  sensibility  (sensations  experienced  by  patient). — 
Localized  pain  in  the  area  of  a  certain  cutaneous  nerve, 
constant  or  periodical,  suggests  enquiry  as  to  Neuralgia. 
Sensibility  may  be  lessened,  anaesthesia  ;  exalted,  hyper- 
esthesia. Sensation  may  be  perverted,  the  patient  ex- 
periencing altogether  abnormal  sensations,  dyssesthesia, 
e.g.,  numbness,  "pins  and  needles,"  a  sense  of  burning, 
heat  and  cold.  If  subjective  sensations  are  complained 
of,  examine  for  an  objective  cause,  e.g.,  local  tenderness, 
local  inflammation  or  disease,  periostitis.  Reflex  causes, 
gasti'ic,  uterine,  etc.  See  Head-pain,  Vertigo,  Hysteria, 
Neuralgia,  Muscular  Anaesthesia. 


MUSCULAR  ANESTHESIA. 

Let  patient  carry  his  hand  to  his  mouth,  and  repeat  the  act 
with  his  eyes  shut ;  let  him  state  the  position  of  his  limbs 
A^-ith  his  eyes  shut ;  let  him  distinguish  between  diff'erent 
weights.  In  all  such  attempts  he  fails.  Test  reflex 
action,  and  electric  excitability  (usually  diminished). 
Note  what  muscles  are  aff'ected ;  state  of  muscular 
nutrition  ;  presence  or  absence  of  pain.  Test  cutaneous 
sensibility. 


DISEASES   OF   THE  NERVOUS   SYSTEM.  0/ 


SENSATION. 

Anaesthesia,  loss  or  diminution  of  sensibility  ;  hypersesthesia, 
exaltation  of  sensibility.  Both  these  conditions  frequently 
met  with  in  Hysteria. 

Hemianaesthesia  is  usually  functional  ;  it  may  paralyse  the 
special  senses  of  side  affected  ;  it  is  frequent  in  hysteria. 
Analgesia  is  the  loss  of  sensibility  to  pricking,  pinching, 
etc.  It  may  be  temporarily  removed  or  transferred  to  the 
other  side  of  the  body. 

Subjective  sensibility  may  be  ansesthetic,  hypersesthetic,  or 
dyssesthetic,  i.e.,  sensibility  may  be  lessened,  exalted,  or 
perverted.  The  brain  centres  of  the  organs  of  special  sense 
may  be  altered  in  any  of  these  ways  ;  so  also  the  sense  of 
touch.  As  sensations  of  physical  life  we  may  speak  of 
"organic  sensations,"  or  those  due  to  the  changes  occurring 
in  the  organs  of  digestion,  circulation,  respiration,  etc.  ; 
the  "appetites,"  a  group  of  uneasy  feelings  produced 
by  the  recurring  wants  or  necessities  of  the  physical 
system,  as  sleep,  exercise,  repose,  thirst,  hunger,  etc. 
Special  dysaesthesise  are  the  epileptic  aura,  the  lightning 
pains  of  ataxy,  the  sensation  of  girthing  frequent  in  spinal 
cord  disease. 

MUSCULAR   ANESTHESIA.* 

' '  A  loss  of  the  feeling  of  muscular  action,  attended  by 
irregularity,  sluggishness,  and  diminished  force  of  volun- 
tary movement ;  but  unattended  by  any  necessary  loss  of 
cutaneous  sensibility  or  by  distinct  paralysis." 

A  condition  frequently  seen  in  Hysteria.  Usually  there  is  no 
pain  in  the  limbs,  but  pain  is  common  in  Locomotor  Ataxy. 
It  may  be  local.  It  often  precedes  paraplegia.  Usually 
impaired  or  lost  in  General  Paralysis.  Some  muscular 
anaesthesia  may  accompany  attacks  of  migraine.  See 
Headache. 

*  Dr.  Reynolds'  "  System  of  Medicine." 


58  CLINICAL   MEDICINE    AND    CASE-TAKING. 

SPECIAL    SENSES. 

Sight. — Test  acuteness  of  vision  witli  test-type.  Examine  for 
perception  of  colour.  To  completely  examine  the  sense  of 
sight,  further  test  poAver  of  accommodation,  refraction, 
action  of  ocular  muscles  separately  and  in  the  combined 
movements  of  the  eyes.  Examine  the  field  of  vision. 
See  Pupils.     Ophthalmoscopic  Appearances. 

Hearing. — Test  hearing  with  a  watch  held  at  the  greatest 
distance  at  which  it  can  be  heard  from  each  ear.  If 
watch  cannot  be  heard  thus,  test  auditory  power  of  the 
nerve  for  sounds  conducted  through  the  skull,  i.e.,  place 
watch  on  forehead  or  between  teeth.  Look  for  otorrhoea  ; 
examine  throat ;  use  ear  speculum. 

Taste. — For  acids,  bitters,  sapid  substances  ;  determine  each 
separately  at  anterior  and  posterior  portions  on  either  side. 

Smell. — For  pungent  substances,  e.g.,  ammonia;  aromatic 
substances,  e.g.,  oil  of  cinnamon. 

CRANIAL  NERVES. 

Observe  movements  of  eyes,  tongue,  face,  lips,  palate,  muscles 

of  mastication  and  deglutition.     Pupils. 
Test  Special  Senses  ;  sensibilit}'"  of  head  and  face. 
Nerve  I.— Olfactory,     See  Smell. 

Nerve  II. — Optic,  see  Sight,  Pupils,  Ophthalmoscopic  appear- 
ances. 
Nerve  III. — (Palsy). — Ptosis  or  drooping  of  the  upper  eyelid  ; 

permanent   external   strabismus  ;   dilated  pupil  ;    loss    of 

accommodation  for  near  objects. 
Nystagmus  =  purposeless  vibratory  movements  of   the  eyes  ; 

usually  the  movements  are  in  the  horizontal  plane. 
Nerve   IV. — Superior    oblique     muscle.      Palsy    produces    no 

appreciable  deviation  of  the  axis  of  the  eye,  but  diplopia 

results    and    the   diagnosis   generally   depends   upon   the 

relative  position  of  the  two  images. 
Nerve  V. — Motor    to    temporals,     masseters,     and    pterygoid 

muscles.     Examine   condition    of  its    separate    branches. 

See    Neuralgia,   Trigeminal.     Examine   power   of  Taste. 

Look  for  tooth  grinding. 


.  DISEASES   OF   THE   NERVOUS   SYSTEM.  59 

SPECIAL   SENSES. 

Sight — Defects  may  occm- from  errors  of  accommodation,  myopia, 
hypermetropia,  or  astigmatism,  from  changes  in  the  optic 
nerve  or  other  parts.  Illusions  may  represent  an  aura 
preceding  an  epileptic  fit ;  common  in  delirium  and  insanity, 
not  uncommon  with  recurrent  Headache. 

Hearing. — Deafness  may  result  from  obstruction  of  the  Eusta- 
chian tube  from  pharyngeal  catarrh,  or  tonsil  disease  ;  wax 
in  ear  ;  disease  of  tympanum.  The  nerve  may  be  paralysed 
from  disease,  e.g.,  Syphilis;  rarely  from  cerebral  tumour. 
Tinnitus  common  with  and  without  ear  disease. 

Taste. — Taste  may  be  lost  on  one  side  only.  It  is  impaired  in 
some  cases  of  palsy  of  Nerve  YII. 

Smell. — Test  either  nostril  separately. 


CRANIAL  NERVES 

Are  some  sensory,  others  nerves  of  special  sense,  while  others 
are  purely  motor.  The  condition  of  the  parts  that  they 
supply,  as  found  on  examination,  often  throws  much  light 
on  the  condition  of  the  brain.  Paralysis  of  an  ocular  muscle 
or  the  tongue  would  indicate  intra-cranial  disease. 

Nerve  III. — Paralysis  often  partial,  e.g.,  ptosis  only.  Accom- 
modative power  alone  may  be  lost,  e.g.,  in  Diphtheritic 
Paralysis.  This  nerve  is  frequently  paralysed  from 
Syphilis. 

Nystagmus. — A  chronic  condition,  usually  congenital,  and 
dependent  upon  deeply-seated  brain  lesion. 

Nerve  V. — Sensory  branches  give  sensibility  to  the  lateral  and 
anterior  parts  of  the  head  and  the  eyeball,  and  common 
sensibility  with  taste  to  the  anterior  two-thirds  of  the 
tongue.  It  is  the  afferent  nerve  in  reflex  winking  on 
touching  the  eyeball  ;  if  palsied,  the  eyeball  becomes 
insensitive  and  the  cornea  ulcerates  and  sloughs.  See 
Neuralgia,  Trigeminal. 


€0  CLINICAL   MEDICINE   AND   CASE-TAKING. 


CRANIAL  NERVES. 

Nerve  VI. — External  rectus  of  the  eye. 

Nerve  VII. — Examine  movements  of  face  in  natural  expression, 
in  forced  voluntary  movements,  e.g.,  to  giin  and  show 
teeth,  to  frown,  to  elevate  the  forehead,  to  whistle.  See 
respiratory  movements  of  alee  nasi.  Facial  movements,  are 
they  symmetrical ;  compare  the  two  sides  of  the  face.  See 
position  of  the  angles  of  the  mouth,  and  slope  and 
curve  of  the  upper  and  lower  lips.  The  depth  of  the  naso- 
labial groove.  Orbicularis  oris,  its  power  of  holding  air  in 
the  mouth  with  the  cheeks  blown  out.  Orhiciilo.ris  oculi^ 
its  action  in  closing  the  eyelids,  in  producing  similar  folds 
of  the  eyelids  on  the  two  sides  ;  a  similar  width  of  palpe- 
bral fissure  on  the  two  sides  ;  a  firm  application  of  the 
lower  eyelid  to  the  globe,  with  the  punctum  applied  to  the 
conjunctiva.  Note  action  of  Occipito-frontcdis  and  Cwru- 
gatoT.  Test  reflex  actions  of  the  eyes.  Note  pronunciation. 
Examine  with  care  the  movement  of  the  soft  palate  and 
tongue.  Test  Hearing,  Sight,  Smell,  Taste.  Look  for 
dryness  of  mouth  from  want  of  saliva. 

Nerve  VIII.  —  Pneumogastric  ;  Glosso-pharyngeal  ;  Spinal 
Accessory^  Pneumogastric.  Not  pui-ely  a  cerebral  nerve  ; 
partly  spinal,  and  receiving  branches  from  the  sympathetic. 

Motor  braiiches. — To  larynx,  pharynx,  oesophagus.  Pharyngeal, 
concerned  in  reflex  act  of  deglutition. 

Sujjerio^'  laryngeal. — Mostly  sensory,  but  motor  to  arytenoid 
and  crico-thyroid.  Its  stimulation  inhibits  inspiration, 
e.g.,  when  opening  of  larynx  is  irritated. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  61 


CRANIAL    NERVES. 

Nerve  VI. — It  is  opposed  by  Nerve  III. 

Nerve  VII. — Motor  to  muscles  of  face,  these  muscles  being 
used  in  expression,  respiration,  eating ;  certain  reflex 
actions,  e.g.,  eyelids,  mouth. 

Intra-cranial  branches. — Ch'eat  petrosal  through  Michel's  gang- 
lion to  levator  palati  and  azygos  uvulae.  Small  2)etrosal 
through  otic  ganglion  to  tensor  palati  and  tensor  tympani 
and  parotid  gland.  Tympanic  branches  to  stapedius  and 
laxator  tympani.  Chorda  tyr)i2Kini  to  submaxillary  gland 
and  lingualis. 

Bell's  Paralysis  of  the  Face  differs  from  the  facial  paralysis 
produced  by  brain  disease  in  being  more  complete  and 
general  in  distribution  ;  in  the  latter  the  muscles  about 
the  angles  of  the  mouth  are  mostly  affected  as  seen  in 
grinning.  Bell's  paralysis  affects  all  the  muscles  on  the 
side  of  the  face  ;  the  eyelids,  however,  retain  a  little 
power.  The  creases  of  the  face  are  obliterated,  as  seen 
on  the  forehead  and  in  the  naso-labial  groove  ;  the  eye 
remains  more  or  less  permanently  open,  and  the  tears 
overflow.  The  patient  cannot  distend  the  mouth  with  air, 
and  food  accumulates  in  the  cheeks. 

Causation. — Cold,  disease  of  ear,  syphilitic  disease  of  temporal 
bone,  pressure  of  glands  on  facial  nerve. 

Nerve  VIII.— 

Pneumogastric  nerve. — Is  concerned  in  certain  reflex  actions,  e.g., 
deglutition,  reflex  movements  of  glottis. 

Pharyngeal  branches. — Palsied  in  Diphtheritic  Palsy,  in  Bulbar 
Paralysis,  and  much  dulled  in  the  Typhoid  State.  Con- 
cerned in  reflex  throat  cough. 

Sicjjerior  laryngeal. — Afferent  nerve  in  reflex  movements, 
closing  larynx  in  deglutition  or  when  irritated. 


62  CLINICAL   MEDICINE   AND   CASE-TAKING. 


CRANIAL    NERVES 


2{erve  VIII. — Continued. 

Recurrent  laryngeal. — Chiefly  motor  ;  supplies  all  the  muscles 
of  the  larynx  except  the  crico-thyroid. 

Cardiac  hranclies. — Inhibitory  ;  pulse  may  be   irregular  from 
brain  disease,  and  small  from  mental  depression. 

Pulmonary  branches. — Afferent  fibres  convey  the  feeling  of  the 
necessity  to  breathe.     Motor  fibres  supply  the  bronchi. 

Gastric  branches. — Regulate  the  peristaltic  movements,  and  the 
secretion  of  gastric  juice. 


Abdomviud  branches. — Supply  liver  and  are  connected  with  the 
renal  plexus. 

Glosso-pharyngeal  nerve. — Gives  common  and  gustatory  sensi- 
bility to  the  tongue,  supplying  circumvallate  papillse  at 
back  of  tongue. 

Spinal  accessory  nerve. — A  motor  nerve  closely  associated  with 
the  pneumogastric  and  giving  it  motor  fibres,  some  of 
which  go  to  larynx. 

Nerve  IX. — Principally  motor  to  the  tongue  and  depressors  of 
the  larynx  and  lower  jaw. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  63 


CRANIAL  NERVES. 


Nerve  VIII. — Continued. 


Recurrent  laryngeal. — Left  winds  round  arch  of  aorta,  right 
round  innominate  artery.  When  paralysed  glottis  is 
passively  narrowed  on  inspiration,  and  passively  dilated 
on  expiration.  It  may  be  paralysed  by  thoracic  Aneurism 
or  mediastinal  tumour,  and  thus  lead  to  palsy  of  cor- 
responding vocal  cord. 

Tulmonary  hranclies. — Concerned  in  spasmodic  Asthma, 
Hooping-cough,  Laryngismus  Stridulus.  When  para- 
lysed leads  to  congestion  of  the  lungs,  e.g.,  in  Typhoid 
State. 

Gastric  branches. — Afferent  in  cerebral  Vomiting.  Dyspepsia 
may  result  from  brain  disturbance. 

Ahdominal  branches. — Mental  shock  may  excite  Diabetes. 
Anxiety  causes  flow  of  pale  urine  of  low  sp,  gr. 

Glosso-pharyngeal  nerve. — It  is  concerned  in  reflex  deglutition 

Spinal  accessory  7ierve. — Motor  to  sterno-mastoid  and  trapezius  ; 
fibres  pass  to  the  larynx  and  control  the  voice,  not  respira- 
tory movements. 

Nerve  IX. — Concerned  in  articulation,  mastication,  and  the 
commencing  act  of  deglutition.  Each  function  may  be 
separately  lost. 


64  CLINICAL   MEDICINE   AND    CASE-TAKING. 


BRAIN  DISEASE,  SIGNS  OF. 

Head-pain  ;  Vertigo ;  Cerebral  Vomiting  ;  Convulsion  ; 
Paralysis ;  Hemiplegia  ;  palsy  of  Cranial  Nerves  ;  sti-abis- 
mus ;  palsy  of  Special  Senses.  Mental  or  intellectual 
disturbance  :  Coma  ;  Aphasia.  Changes  in  Optic  Nerve. 
Pnlse,  interniittence  of.  Pupils.  See  general  condition  of 
the  Nervous  System  ;  Sensation  ;  Hysteria. 

ExoAnirmtion. — Look  for  history  of  neuroses  ;  previous  signs  of 
Brain  Disease.  Indications  of  acute  diseases,  e.g.,  take 
temperature  and  look  for  other  signs  of  Fever.  Examine 
vascular  system  and  urine. 

OPHTHALMOSCOPIC  APPEARANCES. 

Test  sight  and  examine  Pupils  previous  to  using  ati'opine. 
Some  of  the  principal  conditions  of  the  fundus  that  may 
be  observed  are — Optic  Neuritis  ;  Optic  Atrophy,  (1) 
primary,  (2)  secondary  to  neuritis  or  consecutive  atrophy  ; 
over-fulness  of  veins  ;  emptiness  of  arteries  ;  Haemor- 
rhages ;  Choroiditis ;  Tubercle  of  Choroid  ;  retinitis 
albumin  urica. 

OPTIC  NEURITIS. — Disc  blui'red,  outline  indistinct ;  vessels  on 
disc  in  parts  covered  with  effusion  ;  veins  large.  Yision 
may  be  perfect.  ^Neuritis  is  very  indicative  of  coarse 
intra-cranial  disease,  e.g.,  Tumour.  This  condition  may 
subside,  leaving  but  little  change  noticeable,  or  it  may 
leave  consecutive  atrophy.     See  signs  of  Brain  Disease. 

OPTIC  ATROPHY.— May  he  sec|uent  to  neuritis.  It  differs  in 
appearance  from  primary  atrophy  in  having  more 
disturbance  of  the  choroidal  pigment  around  the  disc,  a 
less  sharply-defined  margin,  and  sometimes  thickening  of 
the  sheaths  of  the  vessels  remains  ;  it  looks  dull.  Primary 
optic  atrophy  gives  a  more  clearly-defined  margin  ;  it  is 
clean  cut,  and  its  general  appearance  brighter.  Vessels 
atrophied  or  obliterated. 


DISEASES   or   THE    NERVOUS   SYSTEM.  bD 


BRAIN    DISEASE,    SIGNS    OF. 

The  condition  of  the  brain  may  be  judged  of  by  observation 
of  the  optic  discs  and  retina,  as  expansions  of  nerve  matter 
in  connection  with  the  circulation  of  the  brain.  Also  by 
the  condition  of  parts  supplied  by  nerves  having  their 
centres  in  the  brain.  Special  signs  are  found  in  conditions 
of  the  muscles,  paralysis,  spasm,  convulsion,  want  of 
co-ordination,  etc.     See  Motor  Power. 

Exami nation.  —  Onset  of  acute  febrile  disease  may  cause 
cerebral  symptoms.  Cerebral  symptoms  with  pyrexia 
contra-indicate  a  purely  functional  disturbance. 

OPHTHALMOSCOPIC    APPEARANCES. 

HiEMORRHAGES  in  the  fundus  are  usually  situated  in  the 
retinffi.  They  are  common  in  Pernicious  Anaemia ;  in 
Retinitis  Albuminurica — here  they  are  accompanied  by 
white  shining  spots.  They  may  be  seen  in  ague  and 
leucocythasmia.  Haemorrhages,  even  if  considerable,  may 
be  quickly  absorbed,  and  may  recur. 

CHOROIDITIS.— Dull  yello^vish  patches  over  fundus  ;  there 
may  be  subsequent  atrophy,  the  shining  sclerotic  showing 
through.  Around  the  patches  the  choroidal  pigment  is 
much  disturbed,  forming  black  rings  or  patches.  It  may 
be  disseminated  or  marginal.     It  is  often  syptilitie. 

TUBERCLE  OF  CHOROID.— Small  circular  spots,  more  or  less 
circumscribed,  reddish  or  greyish-white  in  colour.  They 
may  be  elevated  above  the  level  of  the  choroid  with 
retinal  vessels  passing  over  them  ;  adjacent  choroid  may 
be  normal.  Their  growth  in  size  may  be  watched.  See 
General  Tuberculosis. 

TUBERCLE  IN  CHOROID  is  rather  a  sign  of  general 
tuberculosis  than  a  sign  of  meningitis  ;  but  coincident 
optic  neuritis  indicates  probable  tubercular  meningitis. 
Tubercle  in  choroid  in  a  case  of  continued  fever  suggests 
tuberculosis  as  its  cause. 

F 


66  CLINICAL   MEDICINE   AND    CASE-TAKING. 


PUPILS* 


Let  a  full  light  fall  upon  the  face.  Keep  one  eye  covered  and 
test  the  other  ;  letting  light  suddenly  fall  upon  it,  observe 
its  reaction.  Partially  screening  one  eye,  let  light  fall 
suddenly  upon  the  other,  and  observe  the  reflex  effect 
upon  the  first  eye.  This  reaction  involves  the  optic  nerve 
on  side  exposed  to  light,  corpora  quadrigeniina,  and  Nerve 
III.  on  the  side  shaded.  Note  contraction  of  pupil  on 
near  accommodation. 

Observe. — 1.  Its  shape,  regularity,  and  outline  ;  adhesions  may 
cause  irregularity  ;  shape  when  dilated. 

2.  Size  ;    may  be  measured   by  reference  to  the  holes  of 
catheter  gauge. 

3.  Activity  to  light  and  on  near  accommodation. 

4.  Any  differences  between  the  two  pupils. 

5.  Colour  of  iris,  distinctness  of  muscular  bundles. 

Mydriasis  =  great  dilatation  of  pupil.  1.  Artificial,  by  atropine. 
2.  Paralytic,  from  palsy  of  Nerve  III.     3.  Spasmodic. 

Myosis  =■  contraction  of  pupil. 


*  See  Mr.  Hutchinson's  article  on  "  States  of  the  Pupil."    "  Brain," 
Vol.  i.  ii. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  67 


PUPILS. 


Large  in  Anaemia  and  debility  ;  dilated  during  rigor  and 
Convulsion.  May  be  exceedingly  mobile  in  debility. 
Sluggish  pupils  indicate  defect  of  vaso-inotor  nerve,  and 
then  the  pupil  is  rather  small.  A  pupil  sluggish  to  the 
direct  action  of  light  may  respond  immediately  when  the 
other  eye  is  acted  on  by  light,  thus — (1)  Irido-motor  appa- 
ratus is  sound  ;  (2)  Peripheral  structures  of  the  second  eye 
are  sound  ;  (3)  There  is  a  defect  in  the  percipient  structures 
of  the  first  eye.  Pupils  may  remain  active  with  optic 
atrophy.  The  movements  upon  accommodation  (Xerve 
III.)  may  be  good  though  reaction  to  light  (vaso-motor) 
be  lost,  e.g.,  in  Ataxy.  Precise  symmetry  in  size  of  the 
eyes  is  not  common. 

Iridoplegia  —  palsy  of  pupil  to  light,  but  not  to  drugs. 

Cyclojylegia  =  absolute  loss  of  accommodation. 

Ophthahyiojjlegia  interna  =  both  the  radiating  and  circular 
fibres  of  iris  and  the  ciliary  muscle  are  paralysed.  Pupil 
is  motionless  and  accommodation  lost. 

Iritis  may  be  a  sign  of  previous  Syphilis. 


68  CLINICAL   MEDICINE   AND   CASE-TAKING. 


SPINAL    CORD    DISEASE,    SIGNS    OF. 


Paraplegia,  partial  or  complete  ;  Spasms ;  Tremors.  Dysaesthesia, 
principally  confined  to  the  lower  extremities  ;  Paralysis 
of  Sphincters  ;  sacral  bed-sore  ;  atrophy  of  optic  nerve. 

Motor  poiver. — See  power  of  co-ordination  of  the  limbs  ;  their 
state  of  nutrition.  Enquire  as  to  the  state  of  sphincters. 
Test  reflex  action  of  extremities  and  patellar  tendon  reflex.* 
If  there  be  paralysis,  state  what  groups  of  muscles  are 
involved,  and  which  escaped  ;  gait  in  walking. 

Sensation. — Objective  sensibility  ;  examine  the  muscular 
sense.  See  Muscular  Anaesthesia.  Subjective  sensibility  ; 
dyssesthesia  of  lower  extremities. 


Look  for  Ophthalmoscopic  appearances;    condition  of  spine. 
See  Pupils. 


Causatimi. — Exposure  to  cold  ;  over-exertion  ;  functional  para- 
j)legia  in  hysteria  ;  heredity  ;  reflex  paraplegia,  from 
urethral  stricture,  sequent  to  confinement  ;  spinal  menin- 
gitis ;  spinal  hsemorrhage  ;  injury  to  back  ;  Syphilis  ; 
Alcoholism. 


*  Dr.  Gowers:  "Med.-Chir.  Trans."    1879. 


DISEASES   OF   THE   NEEVOUS   SYSTEM.  69 


SPINAL    CORD    DISEASE,    SIGNS    OF, 


Muscles  supplied  by  spinal  nerves  are  alone  paralysed.  See 
if  signs  of  Brain  Disease  and  Palsy  of  Cranial  Nerves  are 
absent.     Paraplegia  may  be  purely  functional. 


Motor  power. — If  there  is  paralysis  of  a  special  gi'oup  of 
muscles,  see  Minor  Paralyses.  Specially  note  the  power 
of  Co-ordination  of  the  Limbs. 


Sensation. — Sensation  of  girthing  round  abdomen,  frequent  in 

spinal  cord  disease. 
*' Lightning  pains,"   darting,  burning,    or  pricking;  common 

prodromata  of  Ataxy,  often  mistaken  for  rheumatism. 

Look  for  sacral  bed-sore,  very  apt  to  form  in  myelitis,  probably 
as  the  direct  effect  of  the  nervous  lesion.  Ko  bed-sore  in 
Hysteria.     Test  reflexes. 

Causation. — Reflex  paraplegia  seldom  complete,  less  widely- 
spread,  and  less  defined  than  paraplegia  from  myelitis. 
See  Paralysis,  Functional  or  Organic. 


70  CLINICAL    MEDICINE    AND    CASE-TAKING. 

MINOR   PARALYSES. 

Paralysis  of  isolated  muscles,  or  groups  of  muscles.  Spinal 
(Infantile)  Paralysis.  Onset  sudden  ;  most  common  in 
infancy ;  frequent  in  liealthy  children  ;  occurs  but  once  ; 
large  muscles  principally  aflected,  e.g.,  deltoid  rather  than. 
muscles  of  fingers. 

PROGRESSIVE  MUSCULAR  ATROPHY.— A  chronic  disease 
causing  atrophy  of  certain  muscles,  with  corresponding 
loss  of  power,  attacking  shoulder  and  ball  of  thumb  by 
preference,  gradually  involving  more  muscles ;  no  pain. 

PSEUD  0-HYPERTROPHIC  PARALYSIS.— Enlargement  of 
muscles  paralysed  ;  usually  attacks  calves,  thighs,  buttocks, 
erector  spinal  muscles  ;  mostly  seen  in  children — male 
children  ;  several  children  in  same  family  may  be  affected. 

PARALYSIS  OF  EXTENSORS  OF  FOREARM.— Usually  due 
to  plumbism. 

CROSS  PARALYSIS.— Palsy  of  face  on  one  side,  and  hemiplegia 
of  the  opposite  side. 

LABIO-GLOSSO-LARYNGEAL  PARALYSIS  (Bulbar  para- 
lysis).— Paralysis  of  muscles  of  tongue,  palate,  pharynx, 
orbicularis  oris  ;  death  by  asphyxia. 

PARALYSIS  OF  THE  FACE.— See  Bell's  Paralysis.  Paralysis 
of  muscles  of  deglutition  frequently  due  to  Diphtheria. 

NETTRALGIA. 

Symptoms. — Onset,  whether  sudden  or  gradual,  whether  pre-; 
ceded  by  general  or  local  disturbance  ;  the  paroxysms, 
whether  severe,  their  frequency,  the  character  of  the  pain. 
The  effect  of  heat  and  cold  upon  the  pain.  Look  for  tender 
points  in  the  course  of  the  nerve  affected,  and  its  branches. 
Examine  cutaneous  sensibility  at  the  seat  of  pain. 

Causation. — Age,  sex,  heredity,  injury  to  neiTe,  frequent  move- 
ment of  the  limb,  or  pressure  upon  a  nerve.  Malaria, 
Syphilis,  Gout,  Rheumatism,  Alcoholism,  Anaemia,  Hysteria, 
cold,  mental  anxiety,  carious  teeth.  Reflex  causes,  e.gf.,  from 
pregnancy,  pain  in  eyeball  from  caries  of  a  tooth. 

Conditions  cTiaroAAerised  hy  neuralgia. — Locomotor  Ataxy,  lower 
extremities ;  Herpes  Zoster,  a  long  area  of  skin  supplied  b; 
nerve  affected  ;  Herpes  Labialis. 


DISEASES    OF   THE   NERVOUS   SYSTEM.  71 

MINOR     PARALYSES. 

Paralysis  of  isolated  muscles,  or  groups  of  muscles.  See 
Infantile  Paralysis. 

PROGRESSIVE  MUSCULAR  ATROPHY.— Enquire  for  injury 
to  nerves  ;  lead  poisoning  ;  the  nature  of  the  employment, 
as  to  its  using  one  particular  set  of  muscles.  Electric 
tests.  Irritability  of  muscles  when  struck.  Cutaneous 
sensibility, 

PSEUDO-HYPERTROPHIC  PARALYSIS.— Test  reflex  action, 

and  electric  tests.     See  motor  power. 

PARALYSIS  OF  EXTENSORS  OF  FOREARM.— Supinator 
longus  and  extensor  carpi  rad.  longior  usually  escape. 

CROSS  PARALYSIS.— May  be  due  to  disease  of  pons. 

LABIO-GLOSSO-LARYNGEAL  PARALYSIS.— Often  accom- 
panies hemiplegia  and  chronic  brain  disease. 

PARALYSIS  OF  FACE.— May  be  due  to  lesion  of  brain,  or 
Bell's  Paralysis. 


NEURALGIA. 

Symptoms. — Pain  localized,  almost  invariably  unilateral  ;  in 
recent  cases  paroxysmal  or  distinctly  intermittent. 
Gradual  formation  of  tender  points,  where  nerve-branches 
become  superficial,  passing  through  bone  or  fascia,  the 
points  of  Valleix.  *  Absence  of  local  causes  of  pain,  sucli 
as  inflammation,  periostitis,  new  growth.  Absence  of  fever 
or  local  heat. 

Causation. — Most  common  in  females  at  puberty  ;  when 
developing  at  forty  years  or  older,  is  very  intractable. 
Malarial  neuralgia,  usually  in  supra-orbital  nerve.  Injury 
to  a  nerve  may  cause  neuralgia  of  branches  communicating 
with  it. 

Conditions  characterized  by  neuralgia. — The  subjects  of  hysteria 
and  epilepsy  are  very  liable  to  neuralgia. 

*  See  Anstie  on  "  Neuralgia." 


72  CLINICAL   MEDICINE   AND    CASE-TAKING. 


NEURALGIA. 

TRIGEMINAL.— Tender  points.  1.  Supra-orbital.  2.  Palpebral, 
iu  upper  eyelid.  3.  Nasal,  at  junction  of  nasal  bone  and 
cartilage.  4.  Ocular,  a  point  in  the  eyeball.  5.  Trochlear, 
at  inner  angle  of  orbit 

Superior  maxillary  division. — 1.  Intra-orbital.  2.  Malar.  3.  A 
point  in  the  line  of  the  upper  jaw. 

Iiiferior  division.  — 1 .  Temporal,   a  little    in  front  of  the  ear. 

2.  Inferior  dental  (mental),   towards  front  of  lower  jaw. 

3.  Lincrual,  at  side  of  tongue. 


SCIATICA. — Is  a  neuralgia  of  the  sensory  fibres  of  the  sciatic 
plexus.  Note  gait  in  walking  ;  the  muscular  power  of 
the  limb  ;  the  state  of  its  nutrition.  Look  for  tender 
points — along  the  com'se  of  the  nerve  and  its  branches,  e^g., 
superficial  cutaneous  branches  in  gluteal  region  ;  down 
back  of  thigh,  calcanean  and  malleolar  branches  ;  also 
behind  trochanter. 


INTERCOSTAL  NEURALGIA.— There  is  pain  and  tenderness 
in  the  course  and  distribution  of  the  nerve  or  nerves 
afiected.  It  is  most  common  in  the  left  infra-mammary 
nerve.  Pain  is  constant,  at  times  shooting.  Painful  points. 
1.  Vertebral.  2.  Lateral,  along  outer  margin  of  trapezius. 
3.  Sternal. 


DISEASES    OF   THE   NERVOUS   SYSTEM. 


NEURALGIA. 

TRIGEMINAL. — Causation  :  Any  cause  of  neuralgia,  especially 
malaria  ;  dental  or  maxillary  disease  ;  cerebral  tumour. 
It  mostly  occurs  in  conditions  of  low  nervous  depression. 
Some  severe  cases  are  associated  with,  hereditary  insanity. 
With  disease  of  trigeminal  nerve  there  may  be  profound 
disturbance  in  the  eyeball,  as  in  cases  of  herpes  in  this 
region.  Ulceration  of  Cornea,  iritis,  suppuration,  and 
disorganization. 


SCIATICA.  —  CaiisaMon :  Rare  under  twenty  years.  Cold  ; 
peripheral  irritation,  e.g.,  tight  boots.  May  arise  from 
pressure  on  the  sacral  plexus,  e.g.,  pelWc  tumours,  ovarian, 
hard  fseces.      Examine  hip-joint. 

Pain  is  more  constant  and  less  paroxysmal  than  in  other 
neuralgia  ;  motor  as  well  as  sensory  fibres  often  affected, 
diminishing  muscular  strength  ;  the  limb  may  emaciate 
and  become  somewhat  ansesthetic.  In  walking,  the  foot 
on  side  affected  is  planted  carefully,  so  as  to  avoid  any  jar 
which  would  increase  the  pain. 


74  CLINICAL   MEDICINE   AND   CASE-TAKING. 


HEMIPLEGIA. 

State  side  affected.  Give  history  of  the  onset,  whether 
sudden,  gradual,  with  convulsion  or  loss  of  consciousness  ; 
whether  preceded  by  abnormal  sensations  ;  whether  first 
attack. 


p, (7, —General  condition  of  Nervous  System.  Look  for  palsy  of 
Cranial  Nerves.  Examine  limbs  affected  as  to  Motor 
Power,  coarse  movements,  e.g.,  power  to  raise  limb  from 
the  bed,  to  move  large  joints,  pronate  and  supinate  ;  to  lift 
weights.  As  to  finer  movements,  e.g.,  use  of  fingers,  to  pick 
up  a  pin,  button  shirt,  point  with  index  and  little  fingers, 
etc.,  to  write.  Note  power  of  tongue  and  face.  Palsied 
limbs,  their  temperature,  atrophy,  or  rigidity,  condition  of 
Sensation.  Look  for  signs  of  Brain  Disease.  Special 
Senses.  Condition  of  cranial  nerves.  Sight,  examine  for 
limitation  of  the  field  of  vision.  Facial  Palsy  from  cerebral 
disease.     Examine  Optic  Discs.     Look  for  bed-sore. 


Causation. — Examine  heart,  and  look  for  signs  of  Vascular 
Degeneration.  Look  for  signs  of  Bright's  Disease.  Look 
for  signs  of  Syphilis.     Hysteria. 

Superficial  reflexes  diminished  on  side  of  palsy.  Rigidity  in 
part  paralysed  later  on.  If  involuntary  movements  of 
parts  palsied. 


DISEASES   OF   THE    NERVOUS   SYSTEM.      -  75 


HEMIPLEGIA* 

Right  hemiplegia  commonly  associated  with  Aphasia.  Hemi- 
plegia from  Embolism  most  commonly  right-sided.  Onset 
sudden  in  embolism,  and  in  cases  of  extensive  haemorrhage. 
Sometimes  premonitory  warnings  are  experienced  in  the 
head  or  limbs. 

P.C. — Nerve  YIL,  when  affected,  is  usually  partially  paralysed, 
muscles  about  mouth  being  most  weakened.  There  may 
be  the  following  phenomena  : — 

1.  Head  turned  to  side  of  lesion. 

2.  Conjugate  deviation  of  the  eyes,  both  being  turned  to  the 

side  of  lesion. 

3.  Muscles  of  chest  and  belly  weakened  on  side  opposite  to 

lesion. 

4.  Paralysis  of  muscles  passing  from  the  trunk  to  the  limbs 

paralysed. 

5.  The  face  paralysed  on  the  side  of  hemiplegia. 

6.  The  tongue  protruded  to  side  of  hemiplegia. 

7.  Arm  and  leg  paralysed  on  the  side  opposite  to  the  lesion. 
Nos.   1   and  2  are  very  temporary.     Those  parts  suffer  most 

and  longest  which  have  the  most  voluntary  uses.     Sensi- 
bility is  usually  restored  before  motor  power. 

Causation. — Valvular  Disease  of  the  Heart  may  lead  to  em- 
bolism, Atheroma  to  cerebral  hsemorrhage  or  thrombus. 
Bright's  disease,  being  associated  often  with  disease  of 
vessels  and  hypertrophy  of  heart,  frequently  leads  to 
cerebral  haemorrhage.     Syphilitic  disease  of  arteries. 

*  Dr.  Hughlings- Jackson :  Reynolds' "  System  of  Medicine." 


CLINICAL   MEDICINE   AND    CASE-TAKING. 


CHOREA. 

If  there  have  been  previous  attacks,  say  whether  one-sided, 
and  state  side  affected.  The  manner  of  commencement. 
Previous  history  as  to  the  general  condition  of  the  Nervous 
System.     History  of  school-life,     Headaches. 

F.  H.  0/ Neuroses,   headaches,  hysteria,  chorea,  fits  in  infancy 
epilepsy.  Rheumatism. 

p.  (7. — Xote  state  of  nutrition  ;  general  condition  of  the  ner- 
vous system.  Look  for  signs  of  Brain  Disease.  Specially 
note  condition  of  Intelligence,  Speech,  Sleep. 

Motor  Power. — Whether  muscles  supplied  by  cranial  and  spinal 
nerves  are  alike  affected.  Examine  face,  tongue,  soft 
palate,  movements  of  eyes,  movements  of  head,  respiratory 
movements,  movements  of  trunk  and  head. 

Examine  the  extremities  in  detail,  e.g.,  right  upper  extremity. 
Is  the  shoulder  much  moved  ?  in  which  direction  principally '? 
by  the  action  of  what  muscles  ?  The  elbow,  is  it  more  or 
less  moved  than  the  shoulder  ;  what  are  the  principal 
movements — flexor,  extensor,  pronator,  or  supinator  ?  The 
hand  ;  movements  of  wrist,  fingers,  thumb.  Fingers  may 
tAvitch  with  extensor-flexor  or  adductor-abductor  move- 
ments ;  some  digits  may  move  more  than  others.  Postures 
of  hands  when  held  out,  also  of  trunk  and  spine. 

Complicatioois.— Onset  of  Rheumatism,  Pericarditis,  Endocar- 
ditis.    Mental  symptoms.     Look  for  Rheumatic  Nodules. 

EoMmine  heart,  its  sounds,  regularity.  Look  for  signs  of 
Anaemia.     Examine  urine  for  urea  and  uro-hfematin. 

Causation. — The  most  distinctly  demonstrated  lines  of  causation 
are  in  connection  with  Rheumatism,  Heart  Disease,  and 

sudden  mental  impressions.  Reflex  causes,  e.g.,  intestinal 
worms,  pregnancy.  Enquire  for  arthritis  with  enlargement, 
attended  with  feverishness  or  not ;  over-work,  or  complaint 
of  school  lessons. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  77 

CHOREA. 

S2)ecial  character  of  the  tnuscular  movements. — Are  the  move- 
ments due  to  mere  clonic  jerks  of  certain  muscles,  repeated 
in  a  meaningless  manner  (muscular  tic),  or  are  they  of  the 
character  of  gesticulations,  wriggling,  testing  movements, 
flinging  the  limbs  about  ?  Do  the  movements  greatly 
displace  the  limbs,  or  after  the  movements  do  the  limbs 
always  fall  back  into  their  previous  position  ?  Are  the 
movements  independent  of  voluntary  efforts  ?  are  they 
increased  by  voluntary  efforts  ?  are  they  equal  on  the  two 
sides  ?  Accompanying  muscular  weakness.  Urine  often 
of  high  sp.  gr.  and  loaded  with  urea. 

SCLEROSIS.*  CHOEEA. 

Rhythmical   oscillations.    In  The     main      direction     of 

lifting  the  arm,  the  main  motion  is  disturbed  from  the 
direction  of  the  movement  outset  by  contradicting  move- 
persists  in  spite  of  the  obsta-  ments  which  cause  the  goal  to 
cles  caused  by  the  jerks  of  the  be  missed.  Movements  sud- 
tremors,  and  it  reaches  its  den,  and  unexpected  when  the 
goal.  limbs  are  at  rest,  and  apart 

from  the  action  of  the  will. 
Complications. — In   pregnant    women    miscarriage  is   frequent 

and  attended  with  danger. 
Examine. — Mitral  bruits,  very  common.  Urine  often  scanty 
and  very  dense,  being  loaded  with  urea  ;  uro-hoematin 
often  in  large  amount. 
Causation. — The  connection  with  rheumatism  is  shown  by  its 
occurrence  before,  after,  or  with  the  chorea.  The  frequency 
of  cardiac  bruits  has  suggested  that  the  disease  is  due  to 
embolism.  If  pregnancy  excites  chorea,  there  has  usually 
been  chorea  in  childhood.  Chorea  most  common  in 
females,  and  in  childhood  near  puberty.  Exciting  causes — 
fright,  falls,  etc. ,  over- work  at  school,  imitation.  Enquire 
for  symptoms  before  occurrence  of  acute  movements ; 
whether    fidgety,    frequently    dropping    things,     clumsy, 

nervous. 

*  Charcot ;  New  Syd.  See.  Trans. 


78  CLINICAL   MEDICINE   AND    CASE-TAKING. 

HYSTERIA. 

Describe  briefly  patient's  complaints.  State  if  able  to  perform 
ordinary  work  ;  if  not,  say  why.  Enquire  if  any  "attacks, 
fits,  or  Convulsions  occur  ; "  if  they  do,  note  time  and  cir- 
cumstance. Note  general  condition  of  Nervous  System; 
signs  of  Brain  Disease. 

Motor    Power.  —  General   character    of    movements,    whether 

active  or  sluggish.     Test  reflex  excitability. 
Setisation. — Should  be  examined  carefully.     Globus  (sensation 

of  a  ball  rising  in  the  throat  and  choking).     Headaches. 

Neuralgia,  specially  Infra-mammary  Neuralgia,   and  of 

Nerve  V.     Look  for  Muscular  Anaesthesia.     Note  mental 

condition  and  Intelligence. 
Causation. — Almost  exclusively  in  female  sex  ;  common  in  early 

life  ;  may  be  very  persistent. 

EPILEPSY. 

A  condition  of  disease  characterized  by  convulsive  paroxysms 
with  loss  of  consciousness.  Look  to  the  general  condition 
of  the  Nervous  System,  and  signs  of  Brain  Disease.  See 
Convulsions.  Note  history  of  onset,  frequency  of 
paroxysms,  their  periodicity  and  characters,  condition  in 
intervals  of  the  paroxysms. 

Paroxysms. — Note  state  of  consciousness,  whether  persistent, 
partially  or  wholly  lost.  Note  carefully  the  degree,  kind, 
and  range  of  Spasm,  whether  Tonic  or  Clonic.  The 
amount  of  fixation  of  respiratory  muscles  and  signs  of 
cyanosis.  Whether  head  is  drawn  to  one  side,  face 
distorted,  or  signs  of  opisthotonos.  Position  of  eyes  and 
state  of  pupils.  Look  for  spasms  in  muscles  supplied  by 
cranial  nerves,  and  one-sided,  local,  or  repeated  movements. 
Condition  of  sphincters.  Temperature,  pulse,  heart. 
Next  passed  urine. 

Starting  points. — (1)  Hand,  usually  index  finger,  thumb,  or 
both  ;  (2)  face,  usually  near  mouth,  or  tongue,  or  both  ; 
(•3)  foot,  usually  great  toe.     Note  range  of  spasm. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  ,79 

HYSTERIA. 

The  will  is  defective  ;  all  voluntary  movements  are  usually 
sluggish  and  wanting  in  energy,  but  movements  excited  by 
emotion  may  be  in  excess.  The  condition  is  most  common 
in  young  females,  and  is  frequently  associated  with 
disordered  menstruation.  A  special  character  is  the  liability 
to  attacks  of  convulsive  nature.  Disturbance  of  Sensation 
is  very  common,  sometimes  assuming  the  form  of  hemi- 
ansesthesia,  one  half  the  body  having  lost  sensibility,  or 
hypersesthesia.  Functional  Paralysis  is  common  in  this 
condition  ;  it  may  be  paraplegic,  hemiplegic,  or  of  a  single 
extremity — functional  aphonia.  Spasm  of  Muscle,  more  or 
less  continued,  is  not  uncommon,  thus  causing  contraction 
of  a  joint,  talipes,  or  a  phantom  tumour  in  the  rectus 
abdominis.  Among  signs  of  disturbance  of  organic  nerves 
are  Vomiting-  and  Angina  Pectoris. 

Causation. — Inherited  tendency  to  neuroses.  Disordered  men- 
struation.    Depressing  mental  circumstances. 

EPILEPSY.* 

Symptoms  of  the  Attack. — Stage  I.  Sudden  loss  of  consciousness ; 
tonic  rigidity  of  muscles  ;  arrested  respiration,  often  with 
a  cry  due  to  forcing  air  through  closed  glottis.  Pallor  or 
duskiness.  Pupils  dilated.  Stage  II. — Unconsciousness 
continues  ;  clonic  convulsion  ;  laboured  breathing  and 
foaming  ;  profuse  sweating.  Stage  III. — Partial  return 
of  consciousness  and  voluntary  power. 

Glasses    of   Paroxysms.  —  I.      Loss    of    consciousness    without 
evident  spasm. 
II. — Loss  of  consciousness  with  local  spasm. 

III. — Loss  of  consciousness   with  general  tonic   and   clonic 
convulsion. 

IV. — "Without  complete    loss   of    consciousness,    convulsion 
being  general  or  partial  (abortive  epilepsy). 
Le  petit  mal  —  classes  I.  and  II. 

*  Dr.  Reynolds'  "  System  of  Medicine." 


80  CLI^'ICAL   MEDICINE   AND    CA.SE-TAKIXG. 


"ETlLEPSY—contimced. 


FremonitoTy  symptoms. — Mental  condition,  excitability,  dul- 
ness,  vertigo,  dyssestliesia.  Aura  epileptica  stiictly 
implies  a  sensation  of  wind  blowing  upon  a  limb.  An 
aui'a  may  commence  in  a  limb,  or  the  epigastrium,  or  in 
tbe  pharynx,  in  each  case  passing  upwards  towards  the 
brain.  An  aura  may  commence  in  an  organ  of  special 
sense,  e.g.,  the  vision  of  a  shape  or  colom",  a  "nasty  taste," 
a  sound,  a  smell,  a  mental  sensation.  The  aura  is 
immediately  followed  by  loss  of  consciousness. 


Sequelce. — Pennanent  impairment  of  intelligence   and   mental 
capacity.    Vertigo. 


Corii2)lications.  —  Post  -  epileptic  mania  may  succeed  the 
paroxysm  ;  in  this  state  acts  of  violence  or  homicide  may 
be  unconsciously  performed.  In  a  condition  after  the 
paroxysms  termed  "  reduction "  the  patient  may  perform 
unconscious  acts,  e.g..  place  things  in  sti'ange  places.  - 


Causation. — Age,  sex,  psychical  causes,  and  heredity.  The 
commonest  antecedents  are  reflex  causes,  teething,  in- 
testinal worms ;  physical  causes,  e.g.,  blows  on  head, 
exposure  to  great  heat. 

Commonest  in  female  sex  and  from  thirteen  to  sixteen  years 
of  age ;  may  be  secondary  to  other  organic  changes  ; 
heart  disease  is  common. 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


81 


CONVULSIONS. 


EPILEPTIC  or 

Onset. — Sudden,  often  with  an 
aura.  Loss  of  consciousness 
usually  complete. 

Prodroma. — Aura  epileptica. 

Asphyxia — Often  very  complete. 

i^ace.— Features  distorted. 

Coma. — Usually  profound,  with 
stertorous  breathing.  Con- 
junetiva  insensible. 

Subsequent  state. — Coma  ;  stu- 
por ;  drowsiness.  Subjunc- 
tival  haemorrhages. 

P'lfi'exia. — May  arise  if  much 
tonic  spasm  is  present. 

Sleep. — Common  during  sleep 
and  when  falling  asleep. 

Tongue. — Often  bitten. 

General  condition.  — Signs  of 
epilepsy. 

Urine.  — Occasionally  contains 
albumen  or  sugar. 


HYSTERICAL. 

Less  sudden,  with  emo- 
tional disturbance.  Loss  of 
consciousness,  more  pro- 
tracted, or  very  apparent. 

Globus  hystericus. 

Flushed,  not  asphyxiated. 

Not  distorted. 

Insensibility  complete.  Re- 
flex movements  of  eye  usually 
continue  on  touching  it. 

Exhaustion. 


Temperature  normal. 


Usual     during     day-time 
when  others  are  about. 

Not  bitten. 

Signs     of     emotional    dis- 
turbance. 

Copious,      limpid,      light- 
coloured,  sp.  gr.  low. 

G 


82  CLINICAL   MEDICINE   AND    CASE-TAKING. 


CEREBRAL     TUMOUR. 

Special  syinptoiiis. — Vomiting,  Head-pain,  Paralysis  of  Cranial 
Nerves,  palsy  of  Special  Senses,  Optic  Nerve  changes, 
Convulsions,  Hemiplegia,  or  other  form  of  Paralysis. 

Temperature  sometimes  very  higli,  witliout  any  inflammation. 

Look  for  Syphilis,  Scrofula,  Phthisis,  Cancer,  or  new  growth 
in  other  parts.  See  Motor  Power,  and  gait  in  walking. 
Examine  urine  for  sugar  and  albumen. 

Causation. — Syphilis.  Scrofulous  diathesis  leading  to  tuber- 
cular mass.     Tubercular  tendency.     Cancer. 

Tumour  may  be  caseous  mass,  gumma,  glioma,  cancer,  growth 
of  pituitary  body,  cyst,  hydatid,   aneurism,  blood-cyst  in 

membranes,  exostosis. 


CEREBRAL     MENINGITIS. 

Xote  sj'mptoms,  with  date  and  manner  of  commencement. 

Special  synvptoms. — See  general  condition  of  Nervous  System, 
signs  of  Brain  Disease,  vomiting,  paralysis  of  Cranial 
Nerves,  intermittent  pulse.  Look  for  signs  of  General 
Tuberculosis,  Phthisis,  strumous  disease.  Ophthalmoscopic 
examination  may  show  tubercles  in  the  choroid.  Note  eyes, 
their  movements,  strabismus,  state  of  Pupils,  photophobia  ; 
general  state  of  nutrition.  Take  temperature.  Examine 
lungs  as  to  phthisis  and  recent  pneumonia  or  pleurisy. 
Examine  urine,  and  note  whether  it  be  retained. 

Look  for  Head-pain,  Vomiting,  ear  disease,  Syphilis.  Take 
temperature. 


DISEASES   OF   THE   NERVOITS    SYSTEM.  83 


CEREBRAL     TUMOUR. 

Head-pain  may  be  localized,  and  permanent,  or  intermittent 
with  exacerbations.  Vertigo  is  common.  Hearing  is  not 
commonly  palsied.     Urine  may  be  saccbarine. 

Convulsions,  partial,  clonic,  or  tonic,  not  uncommon  ;  tbey  may 
resemble  epilepsy,  but  usually  differ  from  such  attacks  as 
follows  : — 1.  Irregular  in  development,  with  less  loss  of 
consciousness  and  no  asphyxia  or  subsequent  coma.  2, 
Not  specially  a  disease  of  female  sex  or  early  period  of  life. 
3.  Less  tendency  to  mental  disturbance.  4.  No  special 
inheritance  of  neurosis.  5.  Characteristic  symptoms  of 
tumour  develop. 

The  course  of  the  disease  is  generally  slow.  Hemiplegia,  if 
present,  usually  develops  slowly  ;  if  on  the  right  side 
may  be  accompanied  by  aphasia.  Preceding  death  the 
temperature  often  rises  high. 

Causation. — Cerebral  tumour  may  cause  ventricular  efiiision, 
resembling  Hydrocephalus. 


CEREBRAL     MENINGITIS. 

Onset  often  insidious  ;  poorliness  and  loss  of  appetite,  with 
head-pain  and  vomiting.  Temperature  is  a  very  uncertain 
sign ;  vomiting,  though  important  when  present,  is 
frequently  absent  throughout.  Intermittence  of  the  pulse 
and  paralysis  of  a  cranial  nerve  are  very  important  signs. 
Tubercles  may  occur  in  the  choroid,  independently  of 
meningitis. 


Causation. — Miliary  Tuberculosis.     Disease  of  ear.     Syphilis, 
Injury  to  head.     Cerebral  Tumour. 


84  CLINICAL   MEDICINE   AND   CASE-TAKING. 


CHEONIC    HYDROCEPHALTJS. 


History  of  family  ;  of  tie  pregnancies  and  labours  of  the 
mother.  State  of  the  head  at  birth,  or  date  at  which 
symptoms  were  first  observed.  Enquire  for  Convulsions. 
iSTote  general  Motor  Power.  Sensation.  Nutrition  ;  power 
to  hold  head  up.  Eyesight.  Hearing.  Intelligence, 
whether  child  notices  sounds  and  colours,  and  plays  with 
toys,  or  is  backward  for  age. 

Head. — Is  it  held  well  up,  well  shaped  ;  its  circumference, 
measurement  from  ear  to  ear,  over  the  vertex,  and  from 
the  nose  to  the  occiput.  State  of  sutui'es  and  fontanelles, 
whether  patent  or  ossified.  Take  tracings  of  skull  with 
cyrtometer. 

Eyes,  whether  of  normal  direction  ;  condition  of  optic  nerve. 
Dentition.    Look  for  signs  of  Eickets. 

Look  f 01'  signs  of  Defective  Development. 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


85 


CHRONIC  HYDROCEPHALUS. 


Must  not  be  mistaken  for  the  large  head  of  rickets.  Con- 
genital hydrocephalus  usually  causes  difficult  labour. 
Head  may  be  normal  at  birth,  subsequently  enlarging. 
Sometimes  accompanied  by  spina  bifida.  Tendency  to 
enlargement  of  the  head  is  progressive. 


HYDROCEPHALUS. 


EICKETS. 


No   signs   of    Rickets,   but  Signs 

signs  of  Brain  Disease.  Rickets. 


and    symptoms     of 


Head  has  a  tendency  to  glo- 
bular shape  ;  eyes  depressed  ; 
often  strabismus ;  optic  nerves 
atrophied.  Cranial  bones  thin. 
Cannot  hold  head  up.  Para- 
lysis common,  or  a  contracted 
limb. 


Head  large,  tending  to 
broadness  and  squareness  ; 
there  may  be  irregular  thick- 
ening of  bones.  No  paralysis, 
head  held  up,  child  playful. 


Tendency  to  increase  of 
relative  size  of  head  to  body, 
indicated  by  measurements. 
Progressive  enlargement ;  pa- 
tency of  fontanelle  continuing. 
Usually  imbecile.  Optic  atro- 
phy. 


As  signs  of  Rickets  pass 
away  the  relative  size  of  the 
head  less  noticeable.  May 
have  good  power. 


86  CLINICAL   MEDICINE   AND    CASE-TAKING. 


ALCOHOLISM. 

See  Nervous  System.  See  Motor  Power.  Tendency  to  tremor  ; 
tongue  tremulous,  coated,  glazed.  Muscular  weakness 
and  want  of  muscular  co-ordination.  See  co-ordination  of 
the  limbs.  Muscular  inquietude  ;  muscular  fidgetiness. 
Look  to  Muscular  Sense  (usually  diminished).  Paralysis, 
Paraplegia.  See  signs  of  disease  of  Spinal  Cord  and 
General  Paralysis.  Flushing  and  congestion  of  the  face 
and  eyes.  Vomiting,  especially  in  the  morning.  Conditions 
of  Sleep.     Neui-algic  pains.     Anaemia. 

Mental  disturbance. — Deterioration  of  mental  power,  restlessness, 
loss  of  memory,  hallucinations,  delusions.  Mental  altera- 
tion, e.g.,  inaptitude  for  business,  avoidance  of  friends. 

Sensation. — Cutaneous  sensibility,  dyssesthesia,  muscse  voli- 
tantes,  buzzing  in  ears,  vertigo.     Note  state  of  nutrition. 

<''omplications. — Look  for  signs  of  disease  of  liver,  kidneys, 
vascular  system,  emphysema.  Acne  rosacea  of  nose. 
Bronchitis.  Pneumonia.  Delirium  and  symptoms  of 
delirium  tremens. 


ACUTE   ALCOHOLISM. 

Excessive  dose  may  produce  Coma ;  breathing  stertorous  ; 
breath  smelling  of  alcohol.  Appearance  of  face.  Examine 
urine  for  albumen  and  alcohol.  Look  for  signs  of  general 
condition  of  Nervous  System.  Vomiting.  Paralysis. 
See  causes  and  examination  of  cases  of  coma.  Examine 
heart  and  condition  of  blood-vessels. 

Look  for — Injury  to  head.  Uraemia.  Simple  exhaustion. 
Meningitis.  There  may  be  Albuminuria  from  acute  renal 
congestion.     Complications  of  chronic  alcoholism. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  87 


ALCOHOLISM. 

Principally  produces  nervous  symptoms  ;  affects  next  the  diges- 
tive system.  Nutrition  may  become  much,  impaired.  In 
chronic  cases,  kidneys  and  liver  often  become  cirrhotic. 
Vascular  system  degenerates.     Emphysema. 

Chronic  Cases. — In  advanced  stages,  the  lower  extremities  may 
become  unsteady,  hands  and  fingers  tremulous,  so  also  the 
tongue.  At  first  the  tremors  may  be  restrained  by 
voluntary  eS'ort.     Acne  rosacea. 

Diagnosis  from — 

Commencing  General  Paralysis  of  Insane,  mind  depressed. 

Paralysis  Agitans. 

Plnmbism,  with  tremor  and  delirium. 

Locomotor  Ataxy. 

Paraplegia,  from  Disease  of  Cord. 

Senile  Degeneration. 

Sclerosis. 

Hysteria. 

Nervous  malaise,  from  simple  dyspepsia. 
Complications. — Cirrhosis    of    Liver     and    Ascites.       Chronic 

Bright's  Disease.     Atheroma  or  Degeneration  of  Arteries 

and  small  vessels.     Chronic  gastritis.     Fatty  degeneration 

of  heart  and  liver. 

ACUTE  ALCOHOLISM. 

Acute  symptoms  may  be  due  to  Delirium  Tremens,  or  to  an 
excessive  dose  causing  toxic  efiects,  e.g.,  coma,  etc.  When 
drunk — Coma,  face  livid,  breath  smelling  of  alcohol,  ten- 
dency to  vomit.  Vomits  or  washings  of  stomach  contain 
spirit.  In  very  deep  coma  there  may  be  strabismus.  There 
may  be  great  excitement  in  place  of  coma.  Cerebral 
haemorrhage  may  occur  during  intoxication.  Alcohol  in 
urine. 


-CLINICAL   MEDICINE   AND    CASE-TAKING. 


DELIRIUM   TREMENS. 

Delirium,  delusions,  illusions  of  Sight  and  hearing.  Vomiting, 
inability  to  take  food.  Intense  restlessness.  Look  for  the 
degenerative  changes  of  chronic  alcoholism.  Specially 
examine  lungs,  urine,  heart,  and  pulse.  ISTote  muscular 
condition,  general  strength,  and  power  of  movement. 
Tremor,  subsultus  tendinum.  Sleep ;  degree  of  con- 
sciousness. 

Complicatwiis. — Typhoid  State.  Subsultus.  Coma.  Heart 
failure  and  pulmonary  congestion.  Syncope.  Albuminuria. 
Pneumonia.     Rapid  development  of  phthisis. 

INSANITY. 

1.  Mania.  2.  Monomania.  3.  Melancholia.  4.  Puerperal 
mania.  5.  Moral  insanity.  6,  Dementia.  7.  Idiocy, 
including  imbecility.     8.  General  Paralysis  or  Paresis. 

Causation. — Heredity  of  primary  importance  ;  enquire  back  to 
the  third  generation  in  the  families  of  each  parent.  See 
also  as  to  collateral  relations. 

Alcoholism.  Habits  and  mode  of  life.  Mental  anxiety. 
Injuries  to  head. 

Signs  of  Insanity. — Talking  to  self,  fantastic  dress,  refusing 
food,  squandering  property,  kleptomania,  self-injury, 
violence,  delusions,  melancholy,  incapacity  for  business, 
avoiding  friends,  delirium.     See  signs  of  Brain  Disease. 

Illusions  of  the  senses.  Sight ;  they  may  be  coloured,  moving 
forms.  Hearing,  smell,  taste,  touch.  The  perception 
of  the  sense  is  mistaken,  and  the  impression  made 
is  false. 

Complications. — Phthisis,  fragile  bones,  heart  disease,  Epilepsy. 
Attacks  of  partial  coma. 

Examination  of  Patients. — Test  Motor  Power,  Pupils,  Muscular 
Sense,  Nervous  System,  Sensation,  heart  and  lungs. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  89 


DELIRIUM  TREMENS. 

Usually  the  efiFect  of  long-continued  drinking,  witli  dyspepsia 
and  deprivation  of  food.  Commences  with  disturbance 
of  general  condition  of  the  Nervous  System ;  diminished 
motor  power.  Insomnia,  night-wandering,  and  horrors, 
with  delusions,  passing  on  to  delirium  with  violence  and 
suicidal  tendency.  Delirium  may  be  busy,  low  muttering, 
or  talkative. 

Complications. — Sudden  syncope  during  violent  struggling  in 
the  delirium  may  lead  to  sudden  death. 


GENERAL  PARALYSIS  OF  THE  INSANE. 

Characterised  by  progressive  diminution  of  mental  power, 
followed  by  paralysis,  involving  the  whole  of  the  muscular 
system.  Pupils  show  want  of  symmetry  of  size,  and  want 
of  mobility.  Mental  condition  characterized  by  an  exag- 
gerated feeling  of  power,  extravagant  exalted  ideas,  loss  of 
memory,  attacks  of  excitement  and  violence.  Hallucina- 
tion ;  delusion. 

Motor  Power. — Failure  first  seen  in  tongue  ;  inaccurate  articu- 
lation, fibrillar  trembling  of  the  tongue.  Pupils  unequal. 
Automatic  and  reflex  actions  lessened  ;  electric  contracti- 
lity of  muscles  retained.  Teeth-grinding.  Late  in  disease, 
SDhincters  lose  their  control,  and  there  is  tendency  to 
choking.     Bones  may  be  very  brittle. 

SeTisation. — Cutaneous  sensibility  usually  diminished,  and  later 
lost.  Muscular  Sense  lost.  Attacks  of  excitement  and 
violence ;  epileptiform  convulsions.  Face  becomes  ex- 
pressionless. 

Diagnosis  from  Alcoholism. — Ideas  of  exaltation  ;  pupils  un- 
equal :  effect  of  removing  alcohol ;  paralysis  of  sphincters. 

Caicsation. — Inheritance,  intemperance  ;  most  common  in  men. 


90  CLINICAL   MEDICINE   AND   CASE-TAKING. 


PARALYSIS  AGITANS. 

State  principal  sites  of  tremor  ;  hemiplegic  type,  paraplegic,  or 
confined  to  one  extremity.  Examine  Motor  Power ;  whether 
movements  of  liead,  face,  tongue  ;  if  speech  be  affected. 
Expression  of  face-  Power  to  walk  ;  gait  in  walking.  Note 
any  tendency  to  involuntary  forward  or  backward  move- 
ment, or  dragging  of  limbs,  etc.  Ability  to  perform 
certain  acts,  walk,  bold  out  limbs,  pick  up  a  pin,  or  write  ; 
keep  specimen  of  writing.  Let  bim  bold  a  glass  of  water, 
and  carry  it  to  bis  moutb.  Note  efi'ect  of  emotion  on 
tremors.     Describe  tbe  Tremor. 


SCLEROSIS  OF  CORD. 

Examine  condition  of  tbe  Motor  Power  and  reflex  excitability. 
Tremors ;  see  wbetber  tbey  cease  during  repose  and  are 
increased  by  voluntary  acts.  Let  patient  raise  a  glass  of 
water  to  bis  moutb,  and  describe  tbe  result.  Let  bim  stand 
and  walk  ;  tben  close  bis  eyes  and  again  perform  tbe  same 
acts.  Note  wbetber  tremors  are  fine  or  coarse.  Note  tbe 
extent  of  parts  affected  by  tremor  ;  wbetber  bead,  trunk, 
and  all  tbe  extremities  are  aflected.  Examine  for  Brain 
Disease.    Ankle  clonus. 


DISEASES    OF   THE   NEEVOUS   SYSTEM.  91 


PAEALYSIS  AGITANS. 

Characterized  by  muscular  tremor,  constant  even  in  repose  ; 
muscular  power  diminislied.  Head  not  tremulous,  but 
may  be  shaken  by  movements  of  the  body.  Tremor  con- 
sists of  jerks,  more  regular  and  rapid  than  in  Disseminated 
Sclerosis.  'No  real  difficulty  of  speech,  but  the  utterance 
is  slow  and  with  jerk-like  effects.  Respiratory  movements 
not  affected.  In  advanced  cases  muscular  rigidity  may 
lead  to  deformity  ;  this  is  specially  seen  in  the  hand. 
There  may  be  a  subjective  sensation  of  heat.  No  Nys- 
tagmus.    Face  stiff,  expression  still. 


SCLEEOSIS   OF   CORD. 


Characterized  by  muscular  tremor,  increased  in  direct  pro- 
portion to  the  extent  of  any  movement  executed.  It  is 
only  manifested  by  voluntary  movements  of  some  extent, 
and  ceases  when  the  muscles  are  in  complete  repose.  The 
oscillatians  are  larger  than  in  Paralysis  Agit'ans,  and  more 
resemble  the  gesticulations  of  Chorea.  Yoluntary  acts 
may  be  performed  despite  the  tremors.  Closing  the  eyes 
does  not  affect  the  tremors,  as  in  ataxy.  Movements  are 
not  seen,  independent  of  voluntary  efforts,  as  in  chorea. 
The  head  is  usually  affected  with  tremor  ;  Nystagmus  is 
common.  Patellar  tendon  reflex  is  exaggerated  in  sclerosis, 
obliterated  in  Ataxy. 


92  CLINICAL   MEDICINE   AND    CASE-TAKING. 


TETANUS. 


General  condition. — T.  =  ;  sweating.  Occurs  in  the  robust 
rather  than  in  the  weak. 

Special  condition  of  muscular  system. — Tonic  spasm.  Trismus 
(lock-jaw).  Opisthotonos,  i.e.,  body  drawn  backwards, 
or  emprosthotonos,  body  drawn  forward.  Eyes  may  be 
retracted  from  spasm  of  recti  muscles.  Face  set  hard  with 
sardonic  grin.     Tetanic  convulsions  frequently  repeated. 

Modes  of  onset.  — Commencing  about  six  days  or  sooner  after 
injury,  may  be  two  to  four  weeks  after  injury.  Injury 
may  have  been  overlooked,  and  the  wound  healed.  The 
earlier  the  commencement,  the  more  rapid  the  case  and  the 
more  certainly  fatal  the  result.  There  is  a  gradual  progress 
of  the  symptoms.  Tonic  contraction  commences  with 
trismus,  extending  to  throat,  back  of  neck,  abdomen. 

Causation. — Injury,  blows,  burn  ;  forcing  bodies  under  skin  or 
under  nail.  Excited  by  exposure  to  cold  ;  war  ;  opera- 
tion. Injury  to  nerve.  Males  rather  than  females. 
Idiopathic  cases  due  to  exposure  to  wet  and  cold  :  this  not 
common.  May  occur  spontaneously  in  infants  within 
eight  days  of  birth. 

Diagnosis. — From  hysterical  opisthotonos.  Strychnia  poisoning. 
Hydrophobia. 


DISEASES   OF   THE   NERVOTJS   SYSTEM. 


93 


TETANUS. 


STEYCHNIA  POISONING.* 


1.  Period  of  onset ;  not  con- 
nected witli  food. 


1.   Onset  soon  after  food. 


2.  Stiffness  first  perceived 
in  jaws  ;  it  tlien  progressively 
extends  downwards,  attacking 
the  body  and  limbs,  the  hands 
not  being  commonly  affected 
till  the  last.  Progressive  in- 
vasion, with  somewhat  gradual 
increase. 


2.  Sudden  and  violent  onset 
of  symptoms :  commences  with 
shivering,  gasping  for  breath, 
trembling  ;  the  body  and  limbs 
are  then  simultaneously  af- 
fected, hands  clenched,  feet 
curved;  at  a  later  date  the 
jaw  becomes  fixed  during  a 
paroxysm. 


3.  Duration  of  the  case 
rarely  less  than  twenty-four 
hours.  Seldom  fatal  in  idio- 
pathic cases. 


3.  Rarely  survive  two  hours 
after  a  fatal  dose. 


4.  Discovery  of  nux  vomica, 
strychnia,  brucin,  or  other 
poison  in  food,  vomits,  or 
washincrg  of  stomach. 


4.  Absence  of  wound,  ulcer, 
or  traumatism  to  account  for 
tetanus  ;  exposure  to  cold,  or 
special  nervous  susceptibility. 


5.  Muscular  rigidity  almost 
without  intermission. 


5.  Intervals  or  remissions  of 
rigidity  of  muscles. 


See  Taylor  on  the  Poisons. 


94  CLINICAL   MEDICINE   AND    CASE-TAKING. 


LOCOMOTOR  ATAXY. 

Examine  condition  of  the  Motor  Power ;  especially  the  gait  in 
walking,  and  co-ordination  of  the  limbs.  Let  him  walk 
■with  his  eyes  open,  then  shut  ;  let  him  walk  with  slight 
assistance  or  using  a  stick.  Also  test  power  to  keep  knee 
flexed  or  extended.  Test  upper  extremities,  e.g.,  precision 
with  which  he  can  touch  an  object,  his  eye  or  nose,  or 
execute  definite  movements.  Reflexes,  and  patellar  tendon 
reflex. 

Electric  Tests. 


Setisation. — Tactile  sensibility  ;  sense  of  heat  and  cold.  Sub- 
jective sensibility  ;  consciousness  of  ground  in  walking  ; 
perverted  sensations  in  lower  extremities.  Sight,  reaction 
of  Pupils,  Ophthalmoscopic  Appearances. 

Examine  the  joints  and  skin.  Look  for  signs  of  Disease  of 
Cord.  Temporary  defects  of  third  nerve  common.  Bowels 
and  action  of  bladder  sluggish.  This  disease  is  often 
associated  with  Syphilis.  Occasionally  gastric  crises  or 
attacks  of  vomiting. 


DISEASES   OF  THE   NERVOUS   SYSTEM.  95 


LOCOMOTOR     ATAXY. 

Characterized  by  difficulty  in  walking,  especially  with  the 
eyes  shut ;  there  being  no  motor  paralysis  and  no  loss  of 
nutrition  of  the  lower  extremities — patient  still  having 
voluntary  power  to  keep  the  limb  flexed  or  extended  with 
good  force.  Commonest  in  males,  and  at  ages  thirty-five 
to  fifty  years.  In  walking  there  is  exaggeration  of  the 
movements  ;  the  feet  are  lifted  too  high  and  the  heel 
brought  suddenly  down.  The  lower  extremities  are  the 
most  afi'ected,  but  there  may  be  want  of  co-ordination  of 
the  upper  extremities  also.  Electric  irritability  not  im- 
paired. Patellar  tendon  reflex  obliterated  more  or  less 
completely.  In  early  stages  "lightning-pains"  in  legs 
and  back  are  usual ;  they  may  last  for  years  and  cause 
much  distress. 

Pupils  usually  small,  inactive  to  light  (vaso-motor  palsy)  ; 
contraction  for  near  accommodation  intact,  i.e.,  ciliary 
muscle  sound — ^it  is  supplied  by  Nerve  III.  ;  ptosis  some- 
times. The  optic  nerves  sometimes  become  white  from 
atrophy.  Large  joints  may  be  the  seat  of  efiusion  and 
chronic  absorption  of  the  cartilages.  It  is  distinguished 
from  disseminated  sclerosis  by  the  marked  increase  of 
symptoms  produced  by  closing  the  eyes  ;  this  does  not  so 
modify  the  rhythmic  jerks  of  sclerosis. 

Perforating  ulcer  of  foot ;  deafness  from  atrophy  of  nerve — some- 
times found. 

Urine  may  be  retained. 


96  CLINICAL   MEDICINE   AND    CASE-TAKING. 


INFANTILE      PARALYSIS. 

History. — General  condition  of  healtli.  Look  specially  for 
Eickets.  Test  general  strength  of  motor  power.  State 
whieli  extremity  is  affected  ;  note  its  state  of  nutrition. 
Examine  tlie  separate  muscles.  Test  reflex  action  and 
sensation.  Electric  Tests.  Observe  temperature  of  the 
paralysed  limb,  and  the  condition  of  the  skin. 


Upper  extremity.  — Can  he  move  the  fingers  separately  ?  point 
with  index  and  little  fingers,  etc.  ?  Movement  of  wrist ; 
power  of  pronation  and  supination  ;  hold  out  the  limb  from 
the  shoulder  ;  put  his  hand  to  back  of  his  head.  Measure 
length  and  circumference,  and  compare  with  opposite  side. 


Lower  extremity.  — Can  child  walk,  stand,  move  toes,  flex  ankle 
and  knee,  or  hold  out  the  limb  1  When  sitting  down  can 
he  get  up  ? 


Catisation. — Age  six  months  to  six  years.  Equally  in  both 
sexes.  Sequel  to  exposure  to  cold  or  an  exanthematous 
fever.     Possibly  due  to  dentition. 


Rigid  contraction  frequently  causes  talipes  in  leg ;  such  de- 
formities much  less  common  in  upper  extremity.  Oc- 
casionally the  bones  do  not  grow  in  length,  and  a  shortened 
limb  results  in  after  life. 


DISEASES    OF   THE   NERVOUS   SYSTEM.  97 


INFANTILE     PARALYSIS 

Occurs  during  ages  from  six  months  to  seven  years,  attacking 
a  certain  muscle  or  gi'oup  of  muscles.  It  is  unattended  by 
pain  or  signs  of  brain  disease.  It  often  occurs  in  children 
apparently  perfectly  healthy.  The  attack  of  paralysis  is 
never  repeated. 

Invasion. — There  maybe  premonitory  symptoms  two  or  three 
days,  or  more  ;  then  the  limb  may  be  found  paralysed. 
Such  premonitory  symptoms  may  be  wholly  absent. 
Onset  not  usually  attended  with  much  distiu'bance  of 
the  general  condition  of  the  nervous  system.  Paralysis 
may  be  noted  without  any  premonitory  symptoms. 

Course  of  disease. — Usually  the  general  health  remains  good. 
Most  of  the  muscles  first  paralysed  usually  regain  power 
in  two  or  three  weeks,  leaving  some  muscles,  or  a  single 
muscle,  e.g.,  deltoid,  permanently  weakened.  In  regaining 
power  the  order  of  recovery  is  the  reverse  of  that  seen  in 
paralysis  from  brain  disease  ;  the  finer  movements  are  first 
regained,  e.g.,  movements  of  fingers  and  toes  before  the 
wrist  and  ankles.  The  muscles  permanently  paralysed 
atrophy.  The  growth  of  the  limb  may  be  checked,  espe- 
cially in  the  lower  extremity.  Permanent  paralysis  may  be 
in  one  leg  only.    The  palsied  limb  becomes  cold  and  bluish. 

Sensation  not  affected.  Reflex  excitability  impaired  or 
abolished,  and  electric  excitability  lost. 


98  CLINICAL   MEDICINE   AND    CASE-TAKING. 

GRAVES'  DISEASE  (Exophthalmic  Goitre). 

Exophthalmos. — Frequently  eyelids  cannot  close  over  eyeballs, 
the  eyes  remaining  open  even  during  sleep.  The  degree 
of  prominence  of  either  eye  is  usually  equal,  but  may  be 
more  marked  on  one  side.  Eyelids  tremble  on  endeavouring 
to  cover  eyeball.  Eyes  appear  staring,  bright,  and 
glistening.  Test  sight  and  optical  refraction,  and  move- 
ments of  eyes.  Ophthalmoscopic  appearances.  Examine 
pupils. 

Goitre. — This  sign  may  be  absent.  Enlargement  usually 
moderate,  "with  a  thrill  felt  and  heemic  murmur  on 
auscultation.  It  is  very  rarely  cystic.  Thyroid  enlarge- 
ment usually  first  seen  on  the  right  side. 

Vascular  system. — Throbbing  in  arteries  of  neck,  and  in  thyroid. 
Hfemic  bruits  over  goitre  and  vessels  in  neck.  Tiolent 
and  frequent  action  of  heart  even  without  exertion.  Left 
ventricle  may  be  dilated.  Valvular  lesion  not  very 
common. 

Com2JilicaMons. — Dilatation  of  heart.  Asphyxiating  attacks. 
Diarrhoea.  Vomiting.  Bronchitis.  Paraplegia.  Head- 
ache. 

PLUMBISM. 

General  condition. — Anaemia  ;  emaciation  ;  gout. 

Digestive  system. — Attacks  of  colic  and  constipation,  may  be 
with  vomiting,  nausea,  loss  of  appetite.  Blue  line  on 
margin  of  gums,  especially  opposite  the  teeth.  Abdomen 
retracted.     Breath  foetid. 

Nervous  system. — Paralysis  usually  of  extensors  of  forearm, 
attended  with  atrophy  and  loss  of  electrical  reaction. 
Usually  paralysis  is  preceded  by  attacks  of  colic  Look 
to  the  general  condition  of  the  Nervous  System.  Motor 
Power.     Sensation.     See  Optic  Discs. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  99 

GRAVES'  DISEASE  (Exophthalmic  Goitre). 

Mainly  cliaracteiized  by  prominence  of  the  eyeballs.  Pulsating 
goitre.  Palpitation.  Usually  there  is  Anaemia  and 
disordered  menstruation.  Emaciation.  Mental  irritability 
and  want  of  sleep.  See  Motor  Power.  There  is  a  tendencj- 
to  intercurrent  attacks  of  diarrhoea  ;  appetite  capricious. 
Occasionally  enlargement  of  liver,  spleen,  and  mammae. 
Frequently  there  is  increase  of  the  symptoms  at  the 
menstrual  periods. 

Pupils. — No  alteration  from  the  normal  ;  natural  size  and 
activity  ;  accommodation  normal. 

Ccmsation. — Usually  develops  in  females  above  age  of  puberty  ; 
rare  in  men.  May  date  from  a  mental  shock  or  period  of 
over-work.  It  is  connected  with  anaemia  and  disordered 
menstruation. 


PLUMBISM. 

Characterized  by  colic,  anaemia,  blue  lines  on  gums.  Paralysis 
of  extensors  of  forearm,  and  brain  disturbance. 

Nervous  system. — There  may  be  profound  disturbance  of  the 
brain ,  Optic  neuritis.  Delirium.  Epileptiform  convulsions. 
General  Tremors.  Palsy  of  the  extensors  of  the  forearm, 
principally  marked  on  the  right  side  ;  the  supinator  longus 
and  extensor  longior  carpi  radialis  escape  palsy. 

Sensation  may  be  at  fault  ;  numbness  in  limbs,  neuralgia, 
headache. 

Complications. — Crout ;  Bright's  Disease ;  optic  nerve  changes  ; 
paralysis. 


100  CLINICAL   MEDICINE   AND    CASE-TAKING. 


DIPHTHERITIC   PARALYSIS. 

History. — Previous  attack  of  sore-tliroat.  Possible  source  of 
infection  ;  evidence  as  to  the  diplitlieria. 

General  condition. — W.  =.     ;  nutrition;  T.  =     . 

Month. — Condition  of  mucous  membrane  as  indicating  previous 
inflammation.  Movement  of  palate  ;  fauces  ;  tongue  ; 
pharynx. 

Nervous  system. — Speech,  whether  nasal  or  twangy,  under- 
standable or  voiceless.     Pain,  giddiness. 

Motor  poiver. — Ability  to  stand  and  walk  ;  gait.  Eyes,  their 
movements ;  vision,  accommodation,  pupils. 

Sensation. — Dyssesthesia,  with  numbness  and  formication,  may 
precede  palsy  in  limbs. 

Urine  may  be  albuminous. 


HERPES   ZOSTER. 

History  of  illness  ;  date  of  onset  of  symptoms,  and  of  the 
appearance  of  rash.  Enquire  as  to  recent  use  of  arsenic. 
Look  to  general  condition,  debility.  Anaemia,  etc. 

Look  for  signs  of  Neuralgia,  condition  of  skin  at  seat  of  pain, 
sensibility,  subjective  pain,  etc,  tenderness,  tender  points 
along  the  course  of  the  nerve  supplying  area  afl'ected. 
Note  any  nutritional  effects  on  parts  affected,  ulceration, 
scars  (with  Nerve  V.  see  Iritis)  ;  note  subsequent  state  of 
Sensation. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  101 


DIPHTHERITIC  PARALYSIS. 

Histm^y. — Palsy  follows  the  sore-throat  in  two  to  six  weeks. 
Primary  illness  rarely  attended  with  laryngitis.  Complains 
usually  as  to  motor  power,  sight,  speech,  deglutition. 

P.  C.  — Area  of  muscular  weakness  may  be  limited  to  fauces  and 
accommodation  of  eyes.  The  limbs,  if  much  weakened, 
emaciate  proportionally.  Respiratory  muscles  may  be 
involved.  Palsy  is  usually  symmetrical ;  lower  extremities 
often  palsied  more  than  upper.  Eye -muscles,  and  tongue 
and  face  may  be  palsied. 

Prognosis. — Cases  usually  recover.  Danger  from  heart  failure, 
choking,  paralysis  of  respirator}''  muscles. 


HERPES   ZOSTER. 

Commonly  occurs  in  young  subjects  ;  it  has  been  noted  as 
common  in  persons  taking  arsenic.  The  disease  does  not 
return.  Pain  precedes  the  eruption  ;  it  may  be  severe  and 
last  for  days.  The  rash  is  vesicular,  vesicles  appearing 
along  the  area  of  a  cutaneous  nerve  ;  the  vesicles  contain 
a  clear  watery  fluid,  and  may  have  inflamed  bases.  The 
patches  seldom  cross  the  median  line,  Vesicles  dry  up 
and  scab  ;    in  debilitated  subjects  ulceration  may  follow. 


102  CLINICAL   MEDICIXE   AND    CA.SE-TAKINU. 

DISEASES  OF  THE  VASCULAR  SYSTEM. 
HEART— PHYSICAL  EXAMINATION. 

riis]3ectlon. — See  front  of  cliest.  Look  for  and  define  apex- 
beat  ;  it  should  be  seen  in  iiftli  space  an  inch  below,  and 
internal  to,  left  nipple.  Look  for  other  sites  of  pulsation. 
Pulsation  of  left  auricle  may  be  seen  in  third  space. 

Palimtion. — Feel  the  general  force  of  the  cardiac  impulse, 
indicating  strong  or  weak  action,  Hypertrophy  or  Dila- 
tation. Determine  area  of  impulse  and  site  of  apex-beat. 
Search  for  a  thrill,  especially  towards  apex  ;  feel  first 
with  tips  of  fingers,  afterwards  mth  ends  of  metacarpal 
bones.  Look  for  friction  fremitus.  See  pericarditis.  See 
Displacement  of  Heart. 

Auscultation. — Listen  for  1st  and  2nd  sounds  ;  each  should  be 
clear  "lub-dub. " 

1st  Sound.  —  Systolic,  coinciding  Avith  the  impulse. 
Loudest  towards  apex  ;  to  be  traced  upwards  to  the  base, 
towards  epigastrium  and  to  axilla.  Note  character  of 
sounds,  sharp,  clear,  feeble,  dull,  prolonged,  or  short,  or 
much  resembling  2nd  sound  (tic-tac).  Accompanying 
bruits  are  termed  systolic. 

2nd  Sound. — Diastolic,  coinciding  Avith  subsidence  of 
cardiac  impulse.  Loudest,  at  level  of  second  costal  car- 
tilage ;  aortic  valves  to  the  right  side  (aortic  cartilage), 
pulmonary  valves  to  the  left  (pulmonary  cartilage). 
Trace  the  sound  to  the  apex.  The  whole  2nd  sound  may 
be  accentuated,  or  either  the  aortic  or  pulmonary  only. 
It  may  be  reduplicated.  Accompanying  bruits  are 
termed  diastolic. 

Cardiac  Mimnurs, — The  fact  of  a  cardiac  mm'mur  being 
decided,  determine  its  periodicity — systolic,  diastolic,  or 
presystolic  ;  the  site  of  maximum  intensity ;  and  relative 
conductivity  in  various  directions,  towards  base  or  apex, 
to  axilla  or  along  sternum,  or  along  the  vessels  at  the  base. 
Observe  if  audible  by  spine  or  at  angle  of  left  scapula. 
Character  of  murmurs — plain  bellows  sound,  musical, 
rasping. 


DISEASES   OF   THE   VASCULAR  SYSTEM.  103 


HEART— PHYSICAL   EXAMINATION. 

liispcction. — May  detect  a  diffused  wave  of  impulse,  e.g., 
Pericarditis.  Hypertropliied  left  auricle  may  be  seen 
pulsating  in  mitral  stenosis  or  contraction  of  left  lung. 
Abnormal  site  of  pulsation  from  Aneurism,  usually  in  right 
third  space.     See  bulging  of  precordium. 

Palpation. — Pulsation  may  be  detected  in  epigastrium  in  dila- 
tation. Thrill  systolic  over  aortic  cartilage  (second  right) 
in  aortic  stenosis  or  aneurism  ;  at  apex  in  mitral  regurgita- 
tion. A  diastolic  thrill  in  base  at  aortic  regui'gitation  ;  at 
apex  just  before  the  systole  in  mitral  stenosis.  Strong 
heaving  impulse  with  hypertrophy. 

Auscultation. — Determine  if  heart's  sounds  are  healthy  and  in 
due  rhythm  ;  if  accompanied  b}^,  or  replaced  by,  abnormal 
sounds  (bruits  or  murmurs)  which  are  generally  due  to 
pathological  conditions  of  the  valves.  jSTote  they  may  be 
due  to  Anaemia  or  Aneurism. 

1st  Sound. — Indicates  the  muscular  condition  of  the  heart, 
and  how  it  is  working  ;  strong  in  Hypertrophy,  weak  in 
degeneration  of  the  walls.  It  may  be  reduplicated  ;  may  be 
masked  by  Emphysema.     Ansemic  bruit  at  base  common. 

2nd  Sound. — Due  to  closure  of  semilunar  valves,  aortic 
and  pulmonary ;  each  should  be  examined  separately. 
Pulmonary  2nd  sound  not  often  accompanied  by  a  bruit 
unless  from  ansemia ;  it  is  accentuated  in  recent  pulmonary 
congestion,  as  from  recent  mitral  regm'gitation.  Aortic 
2nd  sound  accentuated  in  obstructed  arterial  (systemic) 
circulation,  as  in  Bright' s  Disease. 

Cardiac  Murmurs. — If  the  normal  heart's  sounds  are  heard, 
and  the  other  physical  signs  and  the  pulse  are  healthy, 
we  may  conclude  that  the  heart  is  healthy.  If  a  bruit  be 
heard,  look  for  all  the  Signs  of  Heart  Disease  and  the 
presence  or  history  of  some  cause  likely  to  produce  val- 
vular defects.  If  there  be  no  other  proof  of  heart  disease 
than  the  bruit,  look  for  signs  of  Anaemia  and  ansemic 
bruits.     The  character  of  murmurs  often  changes. 


104  CLINICAL   MEDICINE    AND    CASE-TAKING. 

HEART— PHYSICAL   EXAMINATION. 

Percussion. — Detennine  and  mark  out  the  area  of  relative 
and  absolute  precordial  dulness.  In  health  it  extends 
from  about  the  third  left  cartilage  to  the  apex-beat,  being 
limited  below  by  the  line  of  the  liver,  and  not  crossing 
the  median  line.  Area  of  dulness  may  be  diminished  by 
atrophy  of  the  heart,  as  in  old  age,  or  heart  may  be 
overlapped  by  Emphysema  of  the  lungs.  The  area  may  be 
increased  by  pericardial  effusion  as  a  triangle,  larger  than 
the  normal  area,  with  its  apex  towards  the  top  of  the 
sternum. 

PULSE. 

Usually  felt  in  radial  artery ;  it  may  be  examined  in  any 
superficial  artery. 

1.  Frequency. — Frequent  or  infrequent  refers  to  the  number  of 

'pulsations  per  minute.     P.  = 

2.  Quick  or  slotv. — Refers'  to  the  time  occupied  by  each  beat, 

not  including  the  interval  between  it  and  its  successor. 

3.  Bhythm. — Regular  or  irregular  implies  the  order  of  succession. 

Intermittent,  the  occasional  dropping  of  a  beat. 

4.  Large  or  small. — Refers  to  the  degree  of  dilatation  of  the 

artery. 

5.  Jerking  or  collapsing. — Full,    rising    quickly    and    falling 

suddenly. 

6.  Tension. — Soft  or  hard.     Felt  by  the  fingers  and  measured 

by  the  force  required  to  extinguish  the  pulse  by  pressure. 

7.  Dicrotous. — The  wave  is  double-headed  and  the  pulse  soft. 

8.  Locomotor. — When  the  artery  is  seen  to  _'travel  like  a  snake 

under  the  skin. 

State  of  arteries. — Examine  radial,  brachial,  femoral,  dorsalis 
pedis,  temporal,  etc.  The  artery  as  a  piece  of  tissue  may 
be  hard  or  soft,  irregular  on  the  surface,  dilated,  etc. 


DISEASES   OF   THE   VASCULAR   SYSTEM.  105 


HEART— PHYSICAL  EXAMINATION. 

Percussion.  —  H}^erti'opliy  of  right  ventricle  increases  the 
width  of  the  area  of  duhiess,  so  that  it  may  reach  to  the 
right  of  the  median  line.  Hypertrophy  of  the  left 
ventricle  extends  the  dulness  ontwards  and  downwards. 
Abnormal  areas  of  dulness  adjoining  the  heart  may  be 
due  to  Consolidation  of  Lung,  mediastinal  tumour,  or 
Aneurism. 


PULSE. 

May  indicate  the  condition  of  the   cavities  of  the  heart  and 
valves,  and  the  state  of  the  nervous  system. 

1.  Frequency. — High  in  fever  and  in  mental  excitement ;   in 

disease  of  the  valves  and  walls  of  the  heart ;  in  Graves' 
Disease. 

2.  QuicTcness. — Chiefly  affected  by  conditions   of  the   nervous 

system. 

3.  Hhythm. — Irregularity  may  depend  upon  valvular   lesions, 

especially  mitral  disease,  or  on  the  state  of  the  muscular 
walls  of  the  heart;  bra\n  disease,  e.g.,  Meningitis;  reflex 
causes,  e.g.,  dyspepsia. 

4.  Large  or  small. — Depends  upon  strength  of  the  left  ventricle 

and  condition  of  valves.  It  may  be  small  in  mitral  disease 
or  depressed  innervation. 

5.  Jerking. — In  aortic  regurgitation  with  hypertrophy  of  left 

ventricle.  This  character  may  be  less  marked  if  mitral 
disease  coexist. 

6.  Tension. — High  in  Chronic  Bright's  Disease,  and  in  the 

cold  stage  of  ague.  Low  in  Typhoid  State  and  conditions 
of  adynamia. 

7.  Dicrotous. — In  fevers,  especially  in  the  typhoid  state. 

8.  Locomotor. — Indicates  a  hard,  thickened,  or  Atheromatous 

Artery,  or  an  h}'pertrophied  left  ventricle. 
State  of  Arteries. — Rigid,  tortuous,  and  rough  upon  the  surface 
in  atheroma.     See  Vessels,  Disease  of. 


106  CLINICAL   MEDICINE   AND    CASE-TAKING. 


PASSIVE  (Cardiac)  CONGESTION. 

Starting  from  an  obstructed  circulation  on  tlie  left  side  of  the 
lieart,  e.g.,  mitral  obstruction. 

Fulmonary  veins  overfull  (open  into  left  auricle)  ;  receive  blood 
from  pulmonary  capillaries  and  some  of  the  bronchial 
capillaries. 

Bronchial  capillaries  overfull ;  hence  tendency  to 
Bronchitis. 

Pulmonary  capillaries  overfull;  hence  Pulmonary  (Edema, 
i.e.,  effusion  into  air  vesicles. 

PulmoTiary  artery  (leading  from  right  ventricle)  conveys  blood  to 
the  overfull  pulmonary  capillaries  ;  hence  tension  rises  in 
the  pulmonary  artery,  and  pulmonary  2nd  sound  ma^  be 
accentuated. 

Right  ventricle  (drives  blood  into  the  pulmonary  artery,  which 
is  overfull).  It  becomes  over-distended  and  dilated  ;  this 
may  lead  to  Tricuspid  Regurgitation. 

Eight  auricle  (drives  blood  into  the  right  ventricle,  which  is 
overfull).  It  receives  blood  from  superior  and  inferior 
venae  cavse  and  bronchial  veins. 

Superior  vena  cava  receives  blood  from  bronchial  veins;  these 
carry  blood  from  bronchial  capillaries  (which  also  partly 
empty  into  pulmonary  veins) ;  hence  Bronchitis,  The 
bronchial  veins  also  receive  blood  from  the  pleura  ;  hence 
Hydrothorax. 

Jugular  veins,  and  the  veins  of  the  head  and  upper 
extremities,  send  their  blood  to  the  superior  cava  ;  hence 
Cyanosis  of  the  Face,  jugulars  standing  out  in  the  neck, 
Congestion  of  the  Brain,  (Edema  of  the  upper  extremities. 
If  there  be  tricuspid  incompetence,  jugulars  may  be  seen 
and  felt  pulsating. 

[Continued  next  page. 


DISEASES   OF   THE   YASCULAK,   SYSTEM.  107 


PASSIVE  (Cardiac)  CONGESTION. 

Inferior  vena  cava  receives  blood  from  tlie  hejKiiic  vein  ;  hence 
congestion  of  intra-lobiilar  veins  and  hepatic  capillaries  in 
the  lobules  causes  Enlargement  of  the  Liver  and  Jaundice, 
also  obstruction  to  the  outflow  from  the  vena  port»,  and 
congestions  of  the  vessels  emptying  into  the  j^ortal  system, 
viz.,  gastiic,  splenic,  intestinal,  hemorrhoidal  ;  hence 
Spleen  large.  Ascites,  Hsematemesis,  or  Melaena. 

Renal  veins  (branches  of  the  inferior  cava)  receive  the 
veins  which  collect  blood  from  the  capillary  plexus  sur- 
rounding the  uriniferous  tubes  ;  this  plexus  becomes 
primarily  cor<5ested,  and  as  it  receives  blood  from  the 
aft'erent  vessels  of  the  Malpighian  tufts,  these  capillaries 
become  secondarily  congested,  leading  to  Scanty  Secretion 
of  Urine  and  Albuminuria. 

Iliac  and  femoral  veins  return  blood  from  the  lower 
extremities,  and  their  over-fulness  leads  to  capillary  con- 
gestion and  (Edema  of  the  Feet,  the  pressure  being  the 
greatest  in  the  most  dependent  set  of  capillaries. 


IMPORTANT  ANASTOMOSES. 

In  portal  obstruction,  anastomosis  of  inferior  haemorrhoidal  veins 
of  the  internal  iliac  with  branches  of  the  inferior  mesenteric 
of  the  portal  system.  In  portal  obstruction,  blood  flows 
from  intestines  through  the  rectum  to  the  internal  iliac 
veins.     Piles  result. 

In  obstruction  of  inferior  {a\idiOViiinal)  vejia  cava,  e.g.,  by  pressure 
of  a  growth  or  tumom*,  anastomosis  of  epigastric  veins  of  the 
iliacs  with  mammary  branches  of  superior  cava.  Enlarged 
veins  on  abdominal  walls  common  in  ascites. 

Radial  a'od  ulnar  arteries. — When  radial  pulse  is  obliterated  we 
may  have  a  retui'n  current  by  deep  palmar  arch. 


108 


CLINICAL   MEDICINE  AND   CASE-TAKING. 


MITRAL  EEGTJRGITATION. 


MITRAL  OBSTRUCTION 


Inspection.  —  Apex  -  beat  dis- 
placed outwards  and  down- 
wards ;  impulse  diffused. 
Eight  ventricle  probably 
dilated. 


Pulsation  of  hypertro- 
pbied  left  auricle  sometimes 
seen  in  third  left  interspace. 
Right  ventricle  probably 
dilated. 


Palpation.  —  Right  ventricle 
usually  hypertrophied  or 
dilated.  Apex-beat  displaced 
outwards  and  downwards. 

Pulse  frequent,  small,  ir- 
regular. Systolic  thrill  at 
apex.  Heart's  action  may  be 
irregular. 


Right  ventricle  hypertro- 
phied. Thrill  at  apex  jusb 
preceding  impulse. 

Pulse  small. 


Auscultation. — Systolic  bruit  at 
apex  conducted  well  into 
axilla,  also  heard  at  angle 
of  left  scapula.  Pulmonary 
2nd  sound  accentuated. 


Presystolic  bruit  at  apex. 
Pulmonary  2nd  sound  accent- 
uated from  increased  tension 
in  pulmonary  artery.  Aortic 
2nd  sound  feeble  at  apex. 
Bruit  almost  localized  to 
apex-beat. 


Percussion.  — Dilatation   or  hy- 
pertrophy of  right  ventricle. 


Left  auricle  and  right  side 
of  heart  hypertrophied. 
Left  ventricle  not  hypertro- 
phied. 


DISEASES   OF   THE   VASCULAR  SYSTEM, 


109 


AORTIC  REGURGITATION.        AORTIC  OBSTRUCTION, 


Jnspection. — Left  ventricle  Hy- 
pertrophied ;  apex-beat  dis- 
placed outwards  and  down- 
wards ;  much  precordial 
impulse  seen.  Pulse  seen 
locomotor. 


Left  ventricle  hypertro- 
phied,  but  less  dilated  than 
with,  regurgitation. 


JPalpation.  —  Thrill  diastolic, 
distinct  afc  base  ;  great  hy- 
pertrophy of  left  ventricle, 
precordium  thrust  forward  at 
systole,  etc. 

Pulse  full  and  Collapsing. 


Thrill  systolic  over  aortic 
valves.  Signs  of  hypertro- 
phy ;  impulse  strong,  heav- 
ing. 

Pulse  small  or  not  abnor- 
mal. 


Auscultation.  — Diastolic  bruit 
at  aortic  cartilage  and  con- 
ducted down  left  side  of 
sternum. 

■Co-existing  Mitral  disease 
common. 


Systolic  bruit  over  aorfcic 
cartilage  conducted  to  right 
sterno-clavicular  joint. 

Exclude  Anaemic  Bruit. 


Percussion. — Area  of  dulness 
increased  downwards  and 
outwards,  from  hypertrophj'- 
of  left  ventricle. 


110  CLINICAL   MEDICINE   AND    CASE-TAKING, 


HYPERTROPHY   OF   HEART. 

Insijection. — Heart's  impulse  may  loe  seen  over  an  extended 
precordial  area,  shaking  and  thrusting  forward  the  chest- 
walls.  Apex-beat  displaced,  usualh^  outwards  and  down- 
wards. In  children  the  cardiac  area  may  be  bulged 
forward. 

Palpation. — Shock  of  heart  against  chest- wall  very  distinct, 
raising  the  hand  or  stethoscope.  Impulse  felt  in  several 
interspaces.  Epigastric  pulsation  if  right  ventricle  is 
hypertrophied.  Pulse  full  and  strong  in  proportion  to  the 
hyperti'ophy. 

Aiiscidtatioii. — Fu'st  sound  prolonged,  dull,  strong.  Aortic 
2nd  sound  intensified.  '  A-ofe  diagnosis  from  pericardial 
effusion  by  intensity  of  1st  sound  coinciding  ^Yith  increased 
area  of  dulness. 

Percussion. — Area  of  dulness.  Left  ventricle  enlarged  down- 
wards and  outwards,  and  may  extend  a  little  upwards. 
Right  ventricle  enlarged  laterally,  and  may  extend  to 
right  of  sternum. 

HYPERTROPHY   AND   DILATATION. 

Causation — 

Obstructions  in  tlw  jjidmonary  circulation  {right  heart 
affected).  —  Emphysema.  Chi'onic  bronchitis.  Chronic 
pleurisy.     Adhesions  of  lung  preventing  expansion. 

Obstructions  in  tlic  aortic  circulation  {ijrinutrily  aifecting 
left  side). — Arterial  disease.  Chronic  Bright's  Disease, 
^^-ith  thickening  of  small  arteries.  General  plethora. 
Repeated  pregnancies. 

Causes  originating  in  or  about  the  heart. — Primary 
dilatation,  -e.g.,  after  fevers,  in  Anaemia,  Vahoilar  disease 
and  stenosis  of  the  outlets.  Adherent  pericardium.  Ex- 
cessive exercise.  Displacements  of  the  Heart.  Mal- 
formations. Emotional  disturbance  long  continued.  Fatty 
or  other  form  of  degeneration. 


DISEASES    OF   THE   VASCULAR   SYSTEM.  Ill 


DILATATION   OF  HEART. 

Inspection. — Impulse  diffused,  not  bulging  or  shaking  walls 
of  chest.  If  right  ventricle  is  dilated,  epigastiic  pulsation 
may  be  seen,  and  Tricuspid  Eegurgitation  may  lead  to 
pulsation  in  jugular  veins.     Cyanosis  and  dropsy  common. 

Palpaticm. — Impulse  diffused  ;  it  may  be  heaving  if  ventricles 
are  hypertrophied,  or  feeble  if  walls  are  degenerate. 
Impulse  may  be  masked  by  emphysematous  lung  over- 
lapping the  heart.  Pulse  weak,  especially  if  walls  of 
ventricle  are  degenerate. 

Auscultation. — If  walls  of  heart  are  degenerate,  1st  sound 
feeble,  short,  and  much  resembling  2nd  sound. 


HYPERTROPHY  AND   DILATATION. 

Dilatation  of  either  ventricle  may  exist  without  much  compen- 
sative hypertrophy  ;  perhaps  this  is  most  common  on  the 
right  side.  A  dilated  and  hypertrophied  heart  may  be 
capable  of  carrying  on  the  circulation  so  perfectly  as  to 
compensate  for  a  valvular  lesion,  but  when  degeneration 
of  the  heart-walls  follows,  then  signs  of  Cardiac  Congestion 
are  apt  to  supervene.  Very  great  hyperti'ophy  of  the  left 
ventricle  without  any  bruit  or  valvular  lesion  is  common 
with  Granular  Contracted  Kidneys.  The  cardiac  impulse 
and  area  of  dulness  are  often  masked  by  emphysema  of  the 
lungs  ;  but  still,  with  hyperti'ophy  the  pulse  is  strong. 
Examine  heart,  lungs,  urine. 


112  CLINICAL   MEDICINE   AND    CASE-TAKING. 


CARDIAC   DISPLACEMENTS. 

Pleuritic  Effusion,  pushing  the  heart  to  the  opposite  side  ; 
.subsequent  contiaction  of  lung  may  draw  it  to  the  side 
affected.  Cirrhosis  of  lung,  or  other  form  of  contraction, 
drawing  heart  to  side  affected.  Cancer  of  lung,  if  diffused, 
dragging  it  to  side  affected  by  conti'acting.  Mediastinal 
tumour,  cancer.  Aneurism,  glandular,  pushing  heart  aside. 
Abdominal  Tumour,  hepatic,  ovarian,  etc.,  pressing  up 
diaphragm  may  displace  heart. 

VALVULAR  DISEASE. 

Causation.- — Rheumatism,  atheroma,  rupture  of  valves,  scarlet 
fever.  Syphilis,  Alcoholism,  muscular  over-strain,  con- 
genital heart  defect. 

HEART  DISEASE. 

General  symptoms. — Seldom  attended  with  pain,  unless  Angina. 

General  condition. — Anaemia,  mal -nutrition,  (Edema,  haemor- 
rhages, faintness,  languor. 

Digestion. — Dyspepsia,  Jaundice,  Ascites,  Liver  large. 

Vascular  system. — Palpitation.  Irregularity  of  heart's  action. 
Haemorrhages.  Cyanosis.  See  Passive  (Cardiac)  Conges- 
tion. Dropsy.  Embolism.  Irregular  pidse,  feeble,  etc. 
Over-fulness  of  veins. 

Nervous  system. — Distui'bance  of  general  condition  of  Nervous 
System.  Insomnia.  Vertigo,  Headache,  Chorea,  Convul- 
sions, Paralysis,  Angina  Pectoris. 

Respiratory  system. — Orthopncea.  Dyspncea,  especially  on 
exertion.  Respirations  frequent.  Bronchitis,  Emphysema, 
Cough. 

Urine. — Scanty,  with  deposit  of  lithates.  Sp.  gr.  high.  May 
contain  albumen  or  blood. 


DISEASES   OF   THE   VASCULAR   SYSTEM.  Hi 


CARDIAC  BISPLACEMENTS. 

May  be  diagnosed  by  palpation  and  percussion  principally. 
The  heart  may  be  raised  by  pericardial  eflusion.  Apex- 
beat  may  be  displaced  by  cardiac  Hypertrophy  or  Dila- 
tation. Displacement  may  cause  cardiac  dyspnoea,  etc., 
e.g.,  in  cases  of  sudden  pleuritic  effusion. 


VALVULAR  DISEASE. 

Causation. — Rheumatism  usually  attacks  the  mitral  valve,  and 
may  spread  to  the  aortic.  Atheroma  spreads  from  the 
aorta  to  the  valves. 


HEART  DISEASE. 

Enquire  for  signs  and  symptoms  of  heart  disease,  then  make 
a  careful  physical  examination.  Listen  for  the  normal 
sounds,  and  bruits  accompanying  or  replacing  them. 
Look  for  signs  of  Hypertrophy  or  Dilatation.  If  a  bruit 
is  heard,  look  for  signs  of  anaemia.  Note  state  of  pulse 
and  respiratory  system.  Examine  arteries.  Valvular 
lesions  are  often  combined,  e.g.,  aortic  regurgitation  and 
mitral  regurgitation  coexisting,  etc.  Many  symptoms 
result  from  passive  congestion,  e.g.,  oedema,  cyanosis, 
pulmonary  oedema,  bronchitis,  hydrothorax,  haemoptysis, 
large  spleen,  enlargement  of  liver,  jaundice,  ascites, 
Albuminuria,  congestion  of  brain.  These  symptoms  then 
vary  with  the  heart's  condition. 


114 


CLINICAL   MEDICINE    AND    CASE-TAKING. 


PALPITATION. 


FTTNCTIONAL. 

Disturbance  of  the  general 
condition  of  the  Nervous 
System. 

Excessive  smoking,  or  use  of 
tea  and  coffee. 

Often  relieved  by  exercise. 

Frequent  in  recumbent  pos- 
ture. 

Mostly  in  hysterical  women. 

Attacks  intermittent,  as 
causes  producing  them  vary, 
e.g.,  dyspepsia,  menstruation. 

Between  attacks  heart  and 
pulse  natural. 

Often  accompanied  by  neur- 
algic pains. 


ORGANIC. 

Physical  signs  of  disease 
of  walls  of  heart  or  its 
valves. 

Accompanying  general 
Signs  of  Heart  Disease. 

Excited  by  exertion,  re- 
lieved b}''  rest. 

Mostly  while  at  work. 

Mostly  in  men  who  labour. 

Coincide  with  the  amount 
of  exercise,  but  may  be  ex- 
cited by  emotion. 

In  intervals  signs  of  heart 
disease  may  be  best  detected. 

Xot  often  accompanied  by 
distinct  pain,  but  there  may 
be  attacks  of  Angina  Pec- 
toris. 

In  attack,  pulse  small  and 
irretfular. 


Disease  of  walls  of  heart, 
vessels  ;  Aneurism. 


In  attacks  face  may  be 
flushed,  throbbing  in  ears, 
tinnitas  aurium. 

Gout ;  masturbation  ;  want  of 
sleep  ;  Graves'  Disease. 

Cmisation. — Heart  disease  ;  Dilated  Heart ;  Hysteria;  hyper- 
trophied  heart  with  degeneration.  Reflex  uterine  ; 
dyspepsia. 

Exawtine   heart,    its    sounds,    impulse,    regularity.      Look   for 
Vascular  Degeneration. 


DISEASES   OF   THE   VASCULAE,   SYSTEM.  115 


ANGINA  PECTORIS. 

Note  exciting  causes  of  paroxysms,  the  times  and  circumstances 
under  which  they  occur. 

In  the  paroxysm,  note  position  and  attitude  of  patient,  facial 
expression,  ability  to  speak  or  othermse,  state  of  skin  ; 
Pulse,  its  frequency  and  characters  ;  action  of  heart  during 
attack.  Note  state  of  respiration.  Examine  urine  passed 
after  attack.  Examine  heart  and  vessels  in  the  intervals 
of  the  paroxysms. 

It  is  characterized  by  sudden  paroxysms  of  intense  suffering, 
with  the  sense  of  impending  death,  or  a  sense  of  want  of 
air,  burning  pain  in  chest,  or  sense  of  constriction,  pain 
radiating  from  the  chest  down  the  left  arm.  In  paroxysms 
there  may  be  profuse  sweating,  face  pale,  occasionally 
flushed,  palpitation,  subsequent  exhaustion. 

Pulse  may  be  small  and  weak,  or  strong  and  not  frequent. 

Causation. — Organic  disease  of  heart,  walls,  or  valves.  Disease 
of  vessels.  See  Signs  of  Heart  Disease,  especially  hyper- 
trophy and  dilatation.  Atheroma  of  arteries.  Syphilis, 
Aneurism,    over-exertion.    Alcoholism,    Gout,     Hysteria. 

Reflex  exciting   causes,  e.g.,   dyspepsia,    uterine  derange- 
ment, mental  excitement. 


116  CLINICAL   MEDICINE   AND   CASE-TAKING. 


PERICARDITIS. 


Precordial  pain  and  tenderness.  Dyspnoea,  especially  in  upright 
posture.  Tendency  to  syncope.  Palpitation.  Pain  on 
swallowing.     Fever. 


liispection. — A  diffused  wavy  impulse  ma}^  be  seen.  In  young 
subjects  the  precordial  region  may  bulge. 

Palpation. — Precordial  fremitus  may  be  felt,  especially  if 
patient  sit  or  stand  up.  Apex-beat  may  be  elevated  and 
slightly  displaced  outwards.  Tenderness  on  upward 
pressm'e  fi'om  epigastrium.  Pulse  feeble,  irregular,  inter- 
mittent. 


Auscultation. — Friction  sound  not  suspended  on  holding  the 
breath  ;  it  may  be  altered  by  pressure — "  to-and-fro, "  or 
only  systolic  ;  a  brush  or  hard  grating  sound.  Describe 
the  heart's  sounds  heard  as  well  as  these  adventitious 
sounds. 


Percussion. — Tenderness.  Enlarged  area  of  cardiac  dulness  ex- 
tending as  a  triangle,  apex  upwards,  to  second  rib,  and 
even  passing  to  right  of  sternum.  Area  of  dulness  may 
pass  outside  apex-beat. 

Ga.usation. — Rheumatism.  Bright's  Disease.  Scarlet  Fever. 
Erysipelas  and  other  fevers.  Pyaemia.  Cold.  Neighbour- 
ing abscess  or  cancer,  etc. 


DISEASES   OF   THE   VASCULAE   SYSTEM.  117 


PEEICAEDITIS. 

May  coexist  with  other  inflammatory  conditions,  e.g.,  Pneu- 
monia, Pleurisy.  If  valvular  disease  coexist  there  may 
be  orthopnoea.  The  cesophagus  is  in  close  relation  to  the 
pericardium. 

Inspection.  —  Extended  wave  of  impulse  may  be  due  to 
Aneurism  or  Retracted  Lung  exposing  the  left  auricle. 

Palpation. — Fremitus  may  be  absent  in  recumbent  posture, 
if  effusion  be  excessive  or  purulent.  Diffused  impulse 
may  be  mistaken  for  cardiac  dilatation  ;  it  is  weaker  than 
in  cardiac  Hypertrophy. 

Auscultation. — Friction  may  be  inaudible  with  excessive  serous 
effusion  or  with  pus ;  it  ceases  when  adhesion  occurs. 
Friction  of  a  roughened  pleura  moved  by  heart  may 
be  mistaken  for  pericarditis.  Endocardial  murmurs  ma}' 
accompany  those  exocardial. 

Percussion. — Extended  area  of  dulness  may  suggest  hyper- 
trophy, but  in  pericardial  effusion  the  sounds  are  indistinct. 
Extended  dulness,  apparently  cardiac,  may  be  due  to 
solidification  of  the  left  lung. 

Diagnosis. — From  endocardial  murmurs  by  the  friction  being 
felt,  and  being  heard  as  localized  and  not  specially 
conducted  in  certain  directions.  Fremitus  may  be  altered 
by  pressure  of  the  stethoscope  on  the  chest,  especially 
in  young  subjects.  The  friction  is  heard  as  superficial 
and  more  grating  than  an  endocardial  murmiu'. 


118  CLINICAL   MEDICINE   AND    CASE-TAKING. 


CONGENITAL  DEFECTS  OE  THE  HEART. 


Among  the  signs  of  malformation  or  congenital  defects 
of  tlie  heart  and  vessels  there  may  be  cyanosis,  clubbed 
lingers  and  toes,  low  temperature,  a  general  want  of 
development,  or  some  special  deformity  of  the  mouth, 
ears,  fingers,  etc.  Enquu'e  as  to  the  history  of  the 
mother's  pregnancy. 

Make  physical  examination  of  the  heart ;  there  may  be 
hypertrophy  of  one  or  both  ventricles  in  various  forms  of 
malformation.  Tricuspid  Constriction  may  result  from 
fcetal  endocarditis. 

See  Developmental  Defects. 


TRICUSPID  REGURGITATION. 

Systolic  murmur  at  the  lower  part  of  the  sternum  to  its  right 
side  or  near  the  ensiform  cartilage,  not  conducted  to  the 
aorta.  Examine  for  other  valvular  lesions  and  Emphy- 
sema. As  a  primary  disease  it  is  rare,  and  usually 
congenital.  Examine  jugulars  for  venous  pulse,  and  see  if 
they  refill  from  below  when  emptied. 


DISEASES   or   THE   VASCULAR  SYSTEM.  119 


CONGENITAL   DEFECTS   OF   THE   HEART. 

Some  conditions  are  incompatible  with  life.  The  conditions 
most  commonly  met  with  are  communications  between  the 
ventricles  through  the  septum  ;  these  may  be  accompanied 
by  a  systolic  bruit  heard  near  the  base  of  the  heart,  not 
conducted  into  the  arteries.  Cyanosis  is  not  a  necessary 
accompaniment  ;  the  bruit  may  not  be  constant.  Patent 
foramen  ovale  but  rarely  produces  a  murmur  ;  it  is  often 
accompanied  by  a  contracted  pulmonary  orifice,  which 
produces  a  systolic  murmur  at  the  base. 


TRICUSPID  REGURGITATION. 

Usually  secondary  to  mitral  disease  or  emphysema ;  the 
right  ventricle  is  then  hypertrophied.  At  systole 
regurgitation  takes  place  into  the  vena  cava,  causing 
venous  pulse  in  the  neck,  the  pulsation  being  perceptible 
to  sight  and  touch.  It  may  be  temporary  from  over- 
distension of  right  ventricle  during  an  attack  of 
Bronchitis. 


120  CLINICAL   MEDICINE   AND    CASE-TAKING. 


THORACIC  ANEURISM. 

Physical  signs. — Pulsation,  wlien  the  aneurism  points  against 
the  chest-wall,  most  usually  about  third  right  rib.  The 
chest-walls  may  be  bulged,  the  ribs  absorbed,  and  the 
tumour  become  prominent.  Impulse  may  be  felt  with  a 
thrill  at  same  point.  The  heart  may  be  displaced,  but 
is  not  usually  hypertrophied.  The  sternum  or  chest-walls 
may  be  heaved  up  without  any  prominent  tumour.  A 
systolic  or  double  bruit  may  be  heard  at  seat  of  impulse, 
but  not  necessarily  so.  Heart-sounds  may  be  heard 
as  distinctly  over  the  aneurism  as  over  the  heart  itself. 
The  aortic  valves  may  be  incompetent.  Dulness  over 
chest  in  an  abnormal  situation  mthout  signs  of  lung 
consolidation. 

Pressure  signs. — Pressure  on  one  lung  or  bronchus  causes 
dyspncea  on  exertion,  and  loss  of  respiratory  murmur  over 
the  lung  compressed.  Haemoptysis,  or  ulceration  of 
bronchus  or  ti-achea.  Dysphagia  from  pressure  on  the 
oesophagus.  Constant  pain  in  back.  Pressure  on  sub- 
clavian artery  causing  unequal  pulses  in  radials.  Pressure 
on  veins  causing  oedema  and  enlargement  of  superficial 
veins.  Irritation  of  sympathetic  nerve  in  chest  causing 
dilatation  of  the  corresponding  Pupil,  or  its  contraction  if 
nerve  is  paralysed.  Paralysis  of  one  recurrent  laryngeal 
nerve  causing  paralysis  of  the  corresponding  vocal  cord, 
cough,  laryngeal  stridor,  and  metallic-toned  voice.  {Note — • 
the  left  nerve  turns  round  the  arch  of  aorta,  the  right 
round  the  innominate  artery. )  Pressure  on  trachea  causes 
spasmodic  cough,  often  with  tracheal  respiration,  heard 
over  sternum  and  vertebrae. 


DISEASES   OF   THE   VASCULAR   SYSTEM.  121 


THORACIC  ANEURISM. 


Prominent  symptoms. — Pulsation  on  the  surface  of  the  chest, 
vdih  dulness  at  a  point  remote  from  cardiac  impulse  ; 
dyspnoea  on  exertion  ;  stridulous  laryngeal  breathing  from 
paralysis  of  one  vocal  cord  ;  pressure  signs  in  thorax  ; 
Angina  Pectoris ;    Hsemoptysis. 

CoAisatio^n. — Atheroma  of  aorta.  Syphilitic  arteritis.  Strains 
and  injuries.  Most  common  in  men  and  in  middle  and 
later  life.     See  Vessels,  Disease  of. 

Diagnosis  from  chronic  laryngitis  ;  cough  loud  and  paroxys- 
mal with  a  ringing  sound,  laryngoscope  showing  palsy 
of  one  cord  with  no  other  disease.  The  pulmonary 
artery  or  left  auricle  may  be  uncovered  by  retraction 
of  the  left  lung,  and  abnormal  pulsation  on  the  surface 
may  result,  with  an  enlarged  area  of  dulness.  A  cancerous 
tumour  may  be  pulsatile.  Earely,  an  empyema  may 
pulsate. 

Course  of  disease. — The  tendency  of  an  aneurism  is  to  increase 
in  si2e.  If  blood  is  pumped  into  the  sac  at  a  pressure  of 
one  ounce  to  the  square  inch,  that  amount  of  pressure  is 
exerted  on  each  square  inch  of  the  aneurism.  Pressure  may 
cause  absorption  of  vertebrae,  ribs,  sternum.  The  sac  may 
burst  into  the  pleura,  lungs,  pericardium,  oesophagus, 
or  externally,  etc. 

Signs  of  rujjture. — Sudden  or  rapidly  increasing  dyspnoea. 
Paleness. 


122  CLINICAL   MEDICINE  AND    CASE-TAKING. 


VESSELS,   DISEASE  OF. 

Look  for  Anaemia,  Heart  Disease,  (Edema,  Bright's  Disease, 

cutaneous  hsemorrliages,  loss  of  elasticity  of  skin,  SypMlis, 
Gout,  Alcoholism,  Epistaxis. 

Arteries. — Examine  all  the  superficial  arteries,  e.g.,  radials, 
brachials,  temporals,  femorals,  dorsales  pedis,  etc.  Feel  the 
condition  of  the  vessels,  whether  soft  or  hard,  rough  upon 
the  surface,  rigid,  calcareous,  locomotor,  tortuous,  snake- 
like. Embolism  may  occlude  any  artery  in  the  limbs  :  in 
spleen,  causes  its  enlargement  A\ith  tenderness  ;  in  kidney, 
temporary  albuminmia  or  htematuria  ;  in  brain,  hemi- 
plegia.    Retinal  artery  may  be  blocked. 


Veins. — Most  often  diseased  in  lower  exti-emities  ;  may  be 
enlarged,  showing  situation  of  valves.  Varicose  veins  may 
become  hard  from  occurrence  of  thrombosis,  the  clot 
organizing  and  becoming  hard  and  cord-like  ;  then  ulcer 
of  the  skin  may  result. 

Phlebitis  may  occur  during  fevers,  e.g.,  enteric,  scarlet 
fever,  erysipelas,  the  vein  becoming  tender,  swollen,  hard, 
cord-like.  There  may  be  cedema  and  subsequent  abscess. 
Look  for  gout,  pressure  on  the  vein,  cancer,  phthisis,  or 
other  cause  of  great  debility.     Aneemia. 


Capillaries. — Often  seen  dilated  over  malar  bones  in   persons 
exposed  to  the  weather  ;  in  Cirrhosis  of  the  Liver,  chronic 

Bright's  disease,  heart  disease,  alcoholism. 


DISEASES   OF   THE   VASCULAR  SYSTEM.  123 


VESSELS,   DISEASE  OF. 

Often  coexists  with  general  degeneration  of  the  tissues  of  the 
body,  and  especially  of  the  kidneys. 


Arteries. — Disease  may  be  senile  degeneration  or  due  to  local 
injury  or  strain,  atheroma,  gout,  rheumatism,  syphilis, 
alcoholism.  There  may  result  Aneurism,  aortic  incom- 
petency, thrombus,  embolism,  gangrene,  cerebral  haemor- 
rhage. Arteritis ;  if  diseased,  specially  liable  to  give  way 
when  heart  is  hypertrophied,  as  with  Granular  Kidney. 
It  is  apt  to  lead  to  vertigo,  hemiplegia.  Embolism  may 
start  from  a  diseased  valve  or  point  of  atheromatous  artery. 
Onset  of  symptoms  often  sudden  ;  it  may  obstruct  any 
systemic  artery  ;  it  often  occurs  in  brain. 

Veins. — Staining  of  the  legs  in  course  of  veins  may  result 
from  constantly  sitting  before  the  fire.  Varicose  veins 
may  result  from  long  standing  or  constipation.  Phlegmasia 
dolens  after  confinement.  Loss  of  fat  from  the  legs  removes 
their  natural  support. 

Phlebitis,  or  inflammation  of  a  vein.  The  clot  may 
break  down  and  lead  to  pyaemia.  It  may  be  detached 
and  carried  to  the  right  side  of  the  heart,  and  plug 
the  pulmonary  artery  or  a  branch,  causing  dyspncea, 
haemoptysis  from  collateral  hypersemia,  syncope  from 
arrest  of  circulation  in  the  right  heart,  and  sudden  death. 
It  may  occur  deep  in  a  limb. 

Capillaries. — Chronic  capillary  congestion  in  a  limb  often  seen 
when  the  nervous  centres  are  diseased,  e.g.,  paralysis, 
idiocy,  etc.  ;  hands  blue  and  cold  ;  chilblains. 


124  CLINICAL   MEDICINE   AND   CASE-TAKING. 

DISEASES    OF   THE   EESPIRATOEY  SYSTEM. 
CLINICAL  REGIONS   OF   THE   CHEST.* 

Supra-clavicular. — From  outer  end  of  clavicle  to  ti*achea. 


Clavicular.  — Behind  inner  half  of  cla^"icle. 

Infro.- clavicular. — From  clavicle  to  lower  border  of  third  rib, 
and  outwards  to  a  vertical  line  from  the  acromial  angle 
which  divides  the  anterior  from  the  lateral  regions. 

Mammary. — Extends  to  lower  border  of  sixth  rib.  The  nipple 
is  usually"  over  the  fourth  rib. 

Infra-nianvinafi'y. — Extends  to  lower  margin  of  the  ribs. 


Lateral  regions :  Axillo/nj. — From  apex  of  axilla  to  line  con- 
tinuous with  lower  border  of  mammary  region,  and  bounded 
posteriorly  by  scapula. 

Infra-axillary. — Extends  down  to  the  margin  of  the  ribs. 


Upper  and   loioer  scapular  regions. — Above   and   below    spine 

of  scapula. 
Inter -scapular  region. — Between    inner   edge   of    scapula   and 

spines  of  dorsal  vertebra. 
Infra-scapmlar    region. — From  angle  of  scapula  to  margin  of 

ribs. 


Upper  sternal. — Extends  to  lower  border  of  third  rib. 

Lower  sternal. — From  third  rib  downwards. 

*  After  Dr.  Walshe  :  "  Diseases  of  the  Lungs." 


DISEASES   OF   THE   RESPIRATORY  SYSTEM.  125 


CLINICAL   REGIONS   OF   THE   CHEST. 

Supra-clavicular. — Contains  apex  of  lung  ;  this  is  usually 
highest  on  the  right  side  ;  also  portions  of  subclavian  and 
carotid  arteries,  and  large  veins. 

Clavicular.- — Lungs,  large  arteries. 

Infra-clavicular. — Upper  lobe  of  either  lung.  Right  side,  close 
to  sternal  border  lie  the  superior  cava  and  part  of  the 
arch  of  aorta.  Left  side,  edge  of  pulmonary  artery,  the 
base  of  the  heart  being  below. 

Mammary. — Right  side,  middle  lobe  of  lung.  Left  side,  pre- 
cordial area,  sloping  outwards  and  downwards  to  a  point 
about  an  inch  below  and  internal  to  nipple. 

Infra-mammary. — Right  side,  liver  dulness,  the  lung  encroach- 
ing to  a  variable  extent  on  full  inspiration.  Left  side, 
stomach,  and  inner  portion  of  left  lobe  of  the  liver.  Spleen 
rising  to  sixth  rib  in  lateral  region. 

Lateral  regions  :  Axillary. — Contains  upper  lobes  of  the  lungs. 

Infra-axillary. — Lower  margins  of  the  lungs  sloping  down- 
wards and  backwards.  Right  side,  liver  ;  left  side,  spleen 
and  stomach. 

Upper  and  lower  scapular  regions. — Contains  lungs. 

Inter-scapular    region. — Lungs,    main    bronchi,    and    glands, 

descending  aorta,  oesophagus. 
Infra-scapular  region. — Lungs  down  to  eleventh  rib  ;  liver  lies 

below  this   on  right  side.     Left   side   may   be    partially 

occupied  below  by  intestine.     Aorta  descends   along  the 

left  inner  boundary. 
Upper  sternal. — Contains  large  vessels  ;  transverse  portion   of 

the  arch  of  aorta.     Aortic  valves  at  level  of  third  right 

cartilage,  pulmonary  valves   to   the   left.     Bifurcation   of 

trachea  at  level  of  second  rib. 
Lower  ster'nal. — Main  portion  of  right  ventricle  and   a   small 

portion  of  the  left  resting  upon  the  diaphragm  and  liver  ; 

at  upper  part  a  small  portion  of  the  left  lung. 


126  CLINICAL   MEDICINE   AND   CASE-TAKING. 


PHYSICAL  EXAMINATION   OF   THE   CHEST. 

Inspecticrti. — Observe  general  configuration ;  form,  especially  local 
or  on  one  side,  e.g.,  bulging  or  retraction  ;  observe  spine,  if 
straigbt.  Cbest  movements — thoracic,  abdominal.  In 
health,  expansive  movements  are  forward  and  upward.  The 
sternum  moves  forwards  and  upwards  on  inspiration. 
Specially  observe  expansive  movements  in  the  infra-clavi- 
cular regions.  In  calm  breathing,  abdominal  movements 
are  scarcely  observable.  Observe  position  of  heart's  apex- 
beat,  and  the  condition  of  the  intercostal  spaces. 

PATHOLOGICAL   CONDITIONS. 

Exjxinsion,  or  bulging,  may  affect  one  or  both  sides  ;  it  may  be 
general  over  one  side  or  only  affect  a  particular  area. 
Observe  intercostal  spaces,  whether  bulged  or  sunken. 
Look  for  position  of  heart's  apex-beat.  In  all  cases 
carefully  compare  the  corresponding  regions  on  the  two 
sides. 

Betraction,  or  depression,  may  be  general  over  one  or  both  sides 
of  the  chest.  It  may  be  localized  in  one  side,  as  in  jQatten- 
ing  or  retraction  in  the  infra- cla\4cular  region  or  in  the 
axillary  regions.  Examine  spine  ;  it  may  be  bent  to  side 
contracted,  with  dropping  of  that  shoulder.  Contraction  in 
infra-mammary  regions  common  in  infants  from  Rickets 
and  collapse  of  lung. 

Chest  movements. — Deficient  expansion  may  be  bilateral  and 
general,  one-sided  or  local.  There  may  be  a  permanent 
condition  of  expansion,  e.g.,  Pleuritic  Effusion,  or  j)erma- 
nent  Contraction,  In  women,  respiratory  movements  are 
principally  thoracic.  Movements  of  diaphragm  may  be 
restricted  by  various  conditions  of  the  abdomen,  e.g., 
Ascites,  ovarian  tumour,  Abdominal  Tumour, 

Rhythm  of  the  respiratory  act. — In  health,  if  the  total 
dui'ation  of  one  movement  be  taken  at  10,  inspiratory 
movement  =  5,  expiratory  4,  pause  1. 


DISEASES   OF   THE    RESPIRATORY   SYSTEM.  127 


PHYSICAL  EXAMINATION  OF  THE  CHEST. 

Inspection. — The  general  fomi  should  be  symmetrical  on  the 
two  sides,  and  slightly  convex  in  the  infra-clavicular 
regions.  Shoulders  should  be  on  the  same  level,  and  the 
spine  straight.  Specially  observe  movements,  and  Signs 
of  Retraction  in  the  infra-clavicular  regions.  The  two 
sides  of  chest  should  be  symmetrical,  but,  in  men,  muscular 
development  may  cause  greater  fulness  on  the  right  side. 
There  may  be  expansion,  or  bulging,  or  retraction,  or 
altered  chest  movements.  Chest  may  be  deformed  from 
Bickets. 

PATHOLOGICAL    CONDITIONS. 

Expansion,  or  bulging. — General  enlargement  of  both  sides  may 
be  due  to  Emphysema.  If  one-sided  from  Pleuritic  Effusion 
or  pneumothorax,  the  heart  is  then  generally  displaced. 
Local  bulging  may  be  due  to  Aneurism,  mediastinal 
tumour,  encysted  empyema  ;  in  right  infra-axillary  region 
from  enlargement  or  tumour  of  liver.  In  children,  Cardiac 
Hypertrophy  may  cause  local  bulging. 

Retraction,  or  depression,  implies  contraction  of  the  lung  corre- 
sponding, as  from  consolidation  or  pleurisy.  It  may  be 
general  in  atrophous  emphysema.  In  infra-clavicular 
regions  it  is  an  important  indication  of  Phthisis.  Collapse 
of  lung  may  occur  from  Laryngeal  Disease,  and  accompanies 
"  pigeon-breast  "  in  rickets. 

Chest  mowmewfe.— Movement  may  be  restricted  by  the  pain  of 
a  pleuritic  stitch  or  by  pleurodynia  ;  by  ossification  of  the 
ribs,  or  by  conditions  of  the  lung  and  pleura.  Deficient 
movement  in  the  infra-clavicular  spaces  accompanies  con- 
traction of  the  apex.  In  Emphysema  vertical  movement 
of  the  sternum  is  usually  unaccompanied  by  any  forward 
expansive  movement. 

Rhythm  of  the  respiratory  act. — Duration  of  expiratory 
movement  maybe  greater  than  the  inspiratory,  e.g.,  in 
obstruction  to  entry  of  air,  in  emphysema.  Inspiration 
may  be  short  and  abrupt. 


128  CLINICAL   MEDICINE   AND    CASE-TAKING. 

PHYSICAL  EXAMINATION  OF  THE  CHEST. 

Palpation. — Observe  movements  of  tlie  cliest,  both  general  and 
local.  Compare  the  two  sides.  Determine  the  intensity 
of  tactile  vocal  fremitus  (T.V.F.)  in  various  situations.  A 
friction  fremitus  from  pleurisy  or  pericarditis,  or  from  a 
rlionclius  in  young  subjects,  may  be  detected. 

Percussion. — Percuss  each  region  of  the  chest,  and  determine  the 
boundaries  of  the  heart  and  liver,  height  of  apices  of  lungs 
in  neck.  If  the  percussion  note  varies  from  the  normal, 
determine  the  area  of  this  abnormality,  and  compare  with 
the  same  region  on  the  other  side. 
Hyper -resonant  or  tympiccnitic. 

Cracked-pot  sound. — Jerky  and  with  metallic  character. 

Amphoric. — Like  the  sound  of  filliping  the  cheeks  tensely 
distended. 

AUSCULTATION.* 

Kote  separately  inspiration  and  expiration,  their  character,  re- 
lative dui-ation,  and  whether  accompanied  by  adventitious 
sounds.     Auscultate  each  region  of  the  chest. 

Normal  respiration. — Vesicular  murmur  ;  breezy. 

Puerile  respiration. — Exaggerated  in  both  sounds,  increased  in 
intensity,  especially  the  expirator3^ 

ABNORMAL    SOUNDS    FROM     ALTERED    CONDUCTIVITY    OF   LUNG- 
TISSUE. 

Harsh  respiration. — Loss  of  natural  softness  and  breeziness. 
Expiration  increased  in  duration  and  in  intensity. 

BroncMal  respiration. — A  higher  degree  of  harsh  respiration. 

Both  inspiration  and  expiration  are  altered. 
Tubular  respiration. — Air  heard  drawn  in  and  puffed  back  with 

a  metallic  character. 
Cavernoics  respiration. — Hollow  metallic  sound. 

*  These  definitions  are  mostly  quoted  from  Dr.  Walshe,  op.  cit. 


DISEASES    OF    THE   EESPIEATORY   SYSTEM.  129 

PHYSICAL  EXAMINATION  OF  THE  CHEST. 

Palpation. — Of  great  value  in  detecting  local  contractions  and 

impairment  of  niovement.    T.V.F.  (tactile  vocal  fremitus) 

increased   (usually)  over  Solidified  Lung  and  diminished 
over  a  Pleuritic  Effusion. 

Percitssion. — In  healtli,  the  sound  is  resonant,  and  resistance 
vibratile  over  lung.  Sound  approaches  dulness,  and  resist- 
ance increases  with  various  degi'ees  of  consolidation  of  the 
lung,  or  pleuritic  effusion.  Dulness  may  be  noted  on 
superficial  or  deep  percussion  only. 

Hyjjcr -resonant    or    Tympanitic. — Over    Emphysema  or 
Pneumothorax. 

Craclced-pot. — Over    a    vomica  ;     sometimes    in    young 
children  without  disease. 

Amphoric.  — Yomica.     Pneumothorax. 

AUSCULTATION. 

Helps  to  determine  the  physical  condition  of  the  lungs,  and  the 
position  of  their  margins.  In  health,  duration  of  inspi- 
ratory sound  to  the  expiratory  is  as  3  :  1  (inspiratory  move- 
ment of  chest  to  expiratory  as  5  :  6).  Note  separately  the 
respiratory  murmur  and  any  adventitious  sounds. 

Puerile  respiration. — Normal  in  children.  In  adults,  frequently 
due  to  a  portion  of  lung  doing  extra  work  (supplemental 
respiration)  on  account  of  neighbouring  lung-tissue  con- 
solidated or  compressed. 

ABNORMAL   SOUNDS    FROM    ALTERED    CONDUCTIVITY   OF    LUNG- 
TISSUE. 

Harsh  respiration. — In  moderate  degrees  of  consolidation  and 

in  Emphysema. 
Bronchial  respiration. — Indicates  slight  condensation  of  lung 

substance. 
Tubular  respiration. — Perfectly  developed  over  hepatized  lung 

in  pneumonia. 
Cavernous  respiration. — Indicates  probable  cavity  from  phthisis; 

dilated  bronchus. 

K 


130  CLINICAL   MEDICINE   AND    CASE-TAKING. 


AUSCULTATION. 

ADVENTITIOUS   SOUNDS. 

FJionchi. — "Whistling,  cooiug,  bubbling,  crackling  sounds. 

Sonorous  rhonchus. — Inspiratory  and  expiratory  usually; 
sometimes  beard  without  contact  "with  the  chest.  It  is  a 
snoring  sound. 

Sibilant  rhmicJius. — Dry  sounding  ;  high  pitched,  some- 
times hissing;  in  character  ;  ^yhistling. 


CrejJitations  are  crackling  rales  occurring  in  successive  pufi's,  all 
resembling  one  another.  They  may  occur  with  inspiration 
or  expiration. 

Fine  crepitation  resembles  the  sound  produced  by  rubbing 
hair  near  the  ear  ;  it  occurs  on  inspu'ation  in  the  first  stage 
of  Pneumonia. 

Pleural  friction  sound. — Heard  only  with  respiratory  move- 
ments, except  that  occasionally  a  lung,  roughened  at  its 
margin,  is  moved  by  the  heart.  It  may  be  heard  on  inspi- 
ration and  expiration  ;  jerky  in  character  ;  grating  ;  like  a 
simple  brush  ;  or  a  creak  like  that  of  new  leather. 


COUGH. 

Xote  character  and  frequency  ;  paroxysmal,  e.g.,  Hooping 
Cougli ;  whether  occurring  in  prolonged  attacks  ;  accom- 
panied by  Sputa. 

Causation. — Bronchitis;  lung  disease;  Phthisis;  broncho- 
pneumonia ;  Pleurisy ;  Heart  Disease ;  pressure  on  air 
tubes  in  chest,  e.g.,  Aneurism,  mediastinal  tumour,  en- 
larged bronchial  glands.  See  hooping  cough.  Reflex  causes ; 
examine  Mouth,  fauces,  pharynx,  Larynx, 


DISEASES    OF   THE   EESPIEATORY   SYSTEM.  131 


AUSCULTATION. 

ADVENTITIOUS   SOUNDS. 

Rhonchi  may  be  greatly  altered  by  a  cough ;  they  may 
disappear  and  return,  being  much  less  constant  than 
the  frictions,  which  they  sometimes  resemble.  They  are 
characteristic  of  Bronchitis,  and  are  frequently  so  loud 
as  to  mask  all  respiratory  sounds.  The  fremitus  pro- 
duced by  a  rhonchus  may  commonly  be  felt  in  children 
on  palpation. 

Crepitations  may  be  mistaken  for  pleuritic  friction.  Small 
bubbling  crepitations  are  heard  at  bases  in  Pulmonary 
(Edema.  Scattered  crepitations  are  commonly  heard  at 
the  apices  in  Phthisis.  Crepitati<)ns  are  sometimes  absent 
till  patient  has  coughed  and  cleared  the  bronchus  leading 
to  the  seat  of  crepitus. 

Pleural  friction  sound. — It  is  more  lasting  than  a  rhonchus, 
and  cannot  be  coughed  away.  It  indicates  a  roughened 
pleura,  but  may  not  be  heard  in  Pleurisy  on  account 
of  Pleuritic  Effasion,  or  the  hepatization  of  lung  beneath 
pleura  preventing  its  movement. 


COUGH. 

Xot  a  necessary  accompaniment  of  lung  disease,  and  often 
not  dependent  upon  lung  disease.  Prolonged  attacks  of 
coughing  sometimes  cause  so  much  asphyxia  that  tem- 
porary loss  of  consciousness  arises  from  passive  congestion 
of  the  brain. 


132  CLINICAL   MEDICINE   AND    CASE-TAKING. 


SPUTUM. 

Its  amount,  consistence,  whether  aerated,  colour,  mixture  of 
substances,  blood,  colourless,  mixed  with  blood,  streaked 
with  blood,  yellowish,  white  ;  frothy,  mucilaginous- 
looking,  watery,  viscid,  grumous  ;  mucus,  purulent, 
nummulated,  in  viscid  masses. 


H-a:MOPTYSIS. 

Causatimi — 

Valvular  disease  of  left  side  of  heart  (pulmonary). 

Valvular  disease  of  right  side  of  heart  (bronchial). 

Embolism    of    pulmonary    artery    from    peripheral   veins 
(infarction). 

Embolism  of  bronchial  artery  from  left  side  of  heart. 

Blow  on  chest. 

Bronchitis.     Plastic  bronchitis.     Foreign  body  in  trachea. 

Blood  entering  the  larynx  and  coughed  up. 

Aneurism  bursting  into  bronchus. 

Spasmodic  Asthma  (bronchial). 
*     Emphysema.     Asphyxia  (bronchial). 

Scurvy.     Htemorrhagic  diathesis. 

Renal  disease  (vessels  diseased).     Uraemia  (blood  changes). 

Degeneration  of  tissues  and  vessels  (alcoholic). 

Phthisis.     Cancer  of  lung. 

Pneumonia.     Abscess  of  lung. 

Vicarious  menstruation  attended  with  amenorrhcea. 
After  an  attack  of  haemoptysis  there  may  be  signs   of  blood 

having    run    down    to    base   of    lungs    (crejjitations    and 

dulness).      It    may    occur    accidentally    without   organic 

disease.     Hsemorrhage  from  the  throat  may  be  mistaken 

for  haemoptysis. 


DISEASES   OF   THE   EESPIRATOEY   SYSTEM.  133 


SPUTUM. 

Often  frotliy  water,  colourless  in  early  PhtMsis  ;  later  purn- 
lent,  copious,  and  (when  vomicEe  have  formed)  nummulated. 
Viscid,  sticky,  golden  coloured  in  Pneumonia,  and  prune- 
juice  colour  if  mixed  with  blood.  "White,  aerated,  frothy 
in  simple  bronchitis.  Stinking  with  gangrene  of  lung,  and 
in  some  cases  of  dilated  bronchial  tubes. 


Diagnosis  of  HEMOPTYSIS  from        HEMATEMESIS. 

Blood    ejected. — Bright,   frothy.  Dark,  clotted,  mixed  with 

may  be  mixed   with   mucus.       food.     Acid. 
Alkaline. 
Manner    of    ejection. — Coughed  Vomited  mixed  with  food. 

up,   expelled  without   effort  ;       Acid.      Patient  often  faints 
faintness  subsequent  to  ejec-       before  ejection. 
tion.     No  food  expelled. 
Previonitory  symptoms. — Cough,  Signs  of  Ulcer  or  Cancer 

signs  of  Phthisis,  previous  of  Stomach,  pain  with  food, 
specks  of  blood  with  expec-  epigastric  tenderness,  mala- 
toration.  ria.     Cirrhosis  of  Liver, 

Subsequent     symptoms. — Subse-  Subsequent  blood  by  stool, 

quent  expectoration  of  mucus  usually  black,  tar-like 
and  blood.  matter. 

Haemoptysis  is  mostly  due  to  disease  of  the  lungs  or  heart. 
It  may  also  be  due  to  blood  changes,  e.g.,  ursemia.  Care- 
fully examine  heart,  lungs,  urine.  P.  =  ;  T.  =  ; 
E.  =  ;  W.  =  .  Enquire  as  to  history  of  lung  disease 
in  patient  or  his  family,  also  for  early  deaths  in  family. 
General  condition  of  nutrition,  etc.  Haemoptysis  may 
apparently  be  sometimes  purely  accidental  in  a  lung 
previously  healthy,  and  blood  remaining  in  the  lung  may 
set  up  phthisical  changes. 


134  CLINICAL   MEDICINE   AND    CASE-TAKING. 


DYSPNCEA. 

General  condition. — Position  of  the .  patient,  orthopncea,  cya- 
nosis, fulness  of  the  veins,  (Edema,  Anaemia.  P.  =  ; 
T.  =  ;  E,.  =  .  Xote  any  stridulous  breathing  or  sign 
of  Laryngitis.  Respiratory  movements,  whether  thoracic 
or  abdominal ;  if  accompanied  by  collapse  of  the  base  of 
the  chest  or  recession  of  the  epigastrium  on  inspiration. 
Ability  to  speak  ;  voice.  Character  of  the  dyspnoea,  con- 
stant or  paroxysmal  ;  causing  much  distress  ;  attended 
Avitli  pain,  cough,  and  expectoration.  Increased  by  exer- 
tion or  occurring  on  exertion  only  (probably  cardiac). 
Examine  the  lungs,  heart,  urine.  Note  condition  of  the 
cu'culation.  Pulse,  Vessels.  Respiratory  muscles,  if  in  a 
sta-te  of  over-action,  especially  the  sterno-mastoids.  Action 
of  alae  nasi.  Fixation  of  the  arms  to  enable  chest  muscles 
to  act  at  gi'eater  advantage.  General  condition  of  the 
Nervous  System. 


PULMONARY  (EDEMA. 

At  base  of  lungs  abundant  small  bubbling  rales.  T.Y.F.  may 
be  increased  or  diminished.  On  percussion  resonance 
diminished  and  resistance  increased.     Dyspnoea, 

Xote  position  of  patient  ;  signs  of  Typhoid  state.  Examine 
urine,  Xote  general  condition  of  patient,  specially  of 
Nervous  System. 


DISEASES   OF   THE   HESPIEATOEY   SYSTEM.  135 


DYSPN(EA. 

Causation — 

Structural  clmnges. — Emphysema;  PhtMsis;  Pneumo- 
nia; Bronchitis.  (Edema  of  lungs.  Pleuritic  Effusion, 
pneumo-thorax,  acute  pleurisy.  Upward  pressiu'e  of 
diaphragm  from  ascites. 

Conditions  of  pulnionary  circulation. — Congestion.  Heart 
disease.  Emholism  of  pulmonary  artery.  Clot  in  heart. 
Heart  failure  as  when  fatty  or  dilated.  Anemism  or 
mediastinal  tumour  pressing  on  trachea  or  bronchus. 

Laryngeal  obstruction. — Laryngitis  ;  paralysis  of  cord  ; 
growth  upon  cord  ;  oedema  of  larynx. 

General  condition. — ^Ansemia.     Fever.     Uraemia. 

Nerve  co^/iditions. — Asthma.  Hysteria.  Paralysis  of 
nervous  centres.  Graves'  Disease.  Spasm  of  respiratory 
muscles,  e.g.,  from  tetanus. 


(EDEMA  OF   LUNGS. 

In  the  course  of  pneumonia  it  may  occur  in  lung  tissue 
adjacent  to  that  inflamed,  or  in  the  opposite  limg.  May 
attend  hronchitis  or  any  lung  disease.  With  pleuritic 
effusion  may  attack  the  other  lung.  Uraemia ;  Fevers ; 
Passive  (cardiac)  Congestion  from  valvular  disease,  or 
degeneration  of  heart's  walls.  Frequent  in  conditions 
of  prostration  with  dorsal  decubitus. 


136  CLINICAL   MEDICINE   AND    CASE-TAKING. 


CONTRACTION   OF  LUNG. 


Tns'jjection. — Over  portion  of  lung  contracted,  thorax  contracted  ; 
expansion  (inspiratory)  diminislied.  Contraction  of  one  side 
of  chest  suggests  previous  Pleurisy;  of  an  apex,  Phthisis. 
Contraction  of  left  lung  may  uncover  left  auricle.  Look 
specially  at  infra -clavicular  regions  in  adults,  and  at  bases 
in  infants. 

Palpation. — Note  diminislied  expansion,  general,  one-sided,  or 
local.  Position  of  heart ;  it  may  be  drawn  over  by  a 
contracting  lung.  Pulsation  of  left  auricle  may  be  felt  if 
left  lung  is  contracted.     T.Y.F.  may  be  increased. 

Percussion. — Sound  may  be  of  impaired  resonance  from  thicken- 
ing of  pleura  with  lung  consolidation.  The  resistance 
felt  may  be  increased.  Frequently  dulness  exists  from 
coincident  consolidation. 

Area  of  pulmonary  resonance  above  clavicle  diminished  over 
a  contracted  apex. 

Auscultation. — Respiratory  sounds  usually  weak  and  may  be 
abnormal  from  altered  conditions  of  the  lung. 

Look  for  signs  of  Consolidation.     Phthisis. 


DISEASES    OF   THE   EESPIKATOEY   SYSTEM.  137 


SOLIDIFICATION   OF  LUNG. 


Inspection. — Yery  commonly  coincident  signs   of  contraction, 
especially  if  the  consolidation  is  at  the  apex, 


Palpation. — T.V.F.*  increased.  Diminished  expansive  move- 
ment may  also  be  detected.  Note  area  affected,  and 
whether  over  one  or  both  luners. 


FercTission. — Dulness  or  various  degrees  of  impaired  resonance 
may  be  observed  over  area  of  solidification  ;  line  of  dulness 
not  level,  and  changing  with  position  of  patient  as  in 
pleuritic  efiusion.  Note  efiect  of  light  and  deep  percus- 
sion. 


Auscultatiov.. — V.R.f  increased.  Respiration  harsh,  bronchial, 
or  tubular  ;  may  be  cavernous  if  there  be  excavation. 
Puerile  in  neighbourhood  of  consolidation. 

Look  for  signs  of  Contraction  of  Lung ;  Phthisis ;  Pneumonia. 

*  T.V.F.  =  Tactile  vocal  fremitus, 
t  V.E.=  Vocal  resonance. 


138 


CLINICAL   MEDICINE   AND   CASE-TAKING. 


Diagnosis  of  PNEUMONIA  from  PLETJRITIC  EFFUSION. 


Inspection.  —  Expansion  di- 
minished. Ko  contraction 
of  chest  unless  lung  shrinks 
from  chronic  changes. 

Palpation. — T.V.F.  increased 
(sometimes  diminished), 
occasionally  a  pleuritic 
fremitus  felt. 

Mcnsuratiwu  —  Karely  any 
bulging. 

Av^sciUiation.  —  First  stage, 
fine  inspiratory  crepitant 
rales,  often  also  pleuritic 
rub.  Second  stage,  tubular 
respiration.  Rhonchus  or 
scattered  rales.  V.R.  in- 
creased. Resolution:  Redux 
loose  crepitus,  inspiratory 
and  expiratory.  Friction 
sound  may  return. 

Percussion. — Dulness  at  base, 
usually  follo'R'ing  the  line  of 
lower  lobe  downwards  and 
forwards.  Increased  resist- 
ance felt.  No  change  with 
alteration  of  position. 

Determination  of  the  posi- 
tion of  heart  and  liver.  Is  o 
displacement. 


Bulging  of  side  of  chest 
affected,  also  of  the  intercostal 
spaces.  As  fluid  is  absorbed, 
contraction  and  bending  of 
spine  to  side  affected. 

T.V.F.  absent  below  line  of 
dulness ;  may  be  increased 
above.    Fremitus  in  first  stage. 

Bulging  usual.  Tracing  by 
cyrtometer. 

First  stage,  pleuritic  fric- 
tion, inspiratory,  expiratory, 
or  both.  Second  stage,  efiu- 
sion.  Respiratory  murmur 
absent  in  axilla,  frequently 
blo-^ing  respiration  near  spine ; 
puerile  at  apex.  V.R.  absent 
or  ffigophonic.  Resolution : 
Return  of  respiratory  sounds 
at  base.     Redux  friction. 

Line  of  dulness  at  base  level 
coming  round  to  the  front. 
Dulness  shifting  with  position 
of  patient.  May  be  tympan- 
itic above  fluid. 

Heart  displaced,  especially 
with  efiusion  on  left  side ; 
liver  may  be  depressed. 

Hypodermic  syringe  may  be 
used  to  draw  off  the  fluid. 


DISEASES   OF   THE   EESPIEATOEY   SYSTEM.  139 


PLEUEISY. 

Friction   heard   during  inspiration,    or   expiration,    or    during 
both,  periods  ;   it  is  lost  after  effusion  has  occurred,   and 
may  return   after   absorption  of   fluid   or  reduction   of  a » 
pneumonia. 

Friction  fremitus  often  felt. 

Friction  of  pleural  surface  usually  attended  with  pain,  causing 
patient  to  hold  his  breath  ;  he  lies  on  side  affected. 

If  the  pleurisy  be  secondary  to  lung  disease,  e.g.,  phthisis, 
symptoms  will  be  those  of  the  lung  disease.  Pyrexia  in 
pleurisy,  lower  than  the  inflammatory  fever  of  pneumonia. 

See  signs  of  Pleuritic  Effusion,     P.  =     ;  T.  =     ;  R.=     . 

Causation,  see  same  in  Pneumonia. 

Pleuritic  effusion  is  always  albuminous  ;  occasionally  it  coagu- 
lates from  presence  of  fibrin. 


EMPYEMA. 

Often  not  distinguishable  from  serous  effusions  before  tapping. 
It  is  most  common  in  young  subjects,  debilitated  or  very 
strumous.  Also  when  effusion  is  very  chronic.  Tempera- 
ture not  necessarily  high.  More  displacement  of  chest 
walls  and  viscera  than  with  serous  effusion. 

Temperature  often  elevated,  but  not  necessarily  so.  It  may 
point  under  the  skin  in  front  of  chest,  laterally,  or  behind. 
May  occur  in  Septicsemia,  Pyaemia,  Erysipelas,  Scarlet 
Fever,  Puerperal  Fever.     It  may  discharge  by  bronchus. 


HYDROTHORAX. 

Passive  dropsical  effusion  without  pleurisy.  May  occur  from 
Passive  (cardiac)  Congestion,  Bright's  Disease,  etc.  It  is 
usually  double  and  unaccompanied  by  fever. 


140  CLINICAL   MEDICINE   AND    CASE-TAKING. 


PHTHISIS. 


Physical  signs.  —  Signs  of  Consolidation  and  Contraction   of 

Apex  of  lung.  Carefully  ins])ect  movement  in  infra- 
clavicular fossa  on  each  side,  examining  for  signs  of 
contraction  of  tlie  apex.  Palpate,  noting  if  T.V.F.  is 
increased.  In  some  cases  the  left  auricle  is  uncovered 
from  contraction  of  the  left  lung.  Percussion  gives  a  dull 
or  wooden  note  ;  note  the  sound  of  light  or  deep  per- 
cussion. The  resistance  increased  over  consolidated  lung. 
It  may  be  amphoric  over  a  vomica,  but  still  the  resistance 
is  augmented.  Auscultation  shows  V.R.  increased,  respira- 
tion harsh  or  bronchial,  with  adventitious  sounds,  scattered 
rales,  crepitation. 


Digestion. — Dyspepsia  often  troublesome.      Diarrhoea  may  be 
due  to  tubercular  Ulceration  of  Intestines. 


Circulation. — Note  force  and  strength  of  heart's  action  ;  it  often 
partakes  in  the  general  wasting. 


Nervous  system. — General  condition.     Sleep. 


Urine. — Albuminuria  may  be  present.     Diabetes  is  a  frequent 
cause  of  phthisis. 


DISEASES   OF   THE   EESPIEATOET  SYSTEM.  141 


PHTHISIS. 


Cough,  vritli  expectoration  and  Haemoptysis,  debility  and 
weakness,  emaciation.  Sweatings  especially  at  night. 
Flushings  ;  fever  ;  dyspnoea  on  exertion.  Angemia,  and  in 
women  amenorrhoea.  Muscular  irritability  often  marked. 
In  pregnant  women  phthisis  is  often  temporarily  arrested, 
becoming  active  after  parturition.  In  advanced  cases 
there  may  be  cedema  of  the  legs. 


Causation. — Inheritance  ;  history  of  consumption  or  Scrofulous 
disease  in  family  ;  give  ages  of  any  members  of  the  family 
who  died.  Hygienic  conditions,  locality  of  residence  with 
regard  to  climate  and  dampness,  dusty  trades.  Exposure 
to  cold.  Sequent  to  acute  lung  diseases,  or  haemoptysis. 
A  common  termination  in  diabetes  mellitus. 

Possibly  it  is  communicated  from  the  diseased  to  persons 
predisposed. 


Complications. — Laryngitis,    bronchitis,    pneumonia,    heemop 
tysis.  Pleurisy,  empyema,  pneumo-thorax. 

Failure  of  heart's  action  ;  thrombosis  ;  bed-sores.  Diarrhoea  or 
Melsena  from  tubercular  ulceration  of  intestines  ;  fistula  ; 
Peritonitis  ;  Liver  large,  fatty  or  amyloid  ;  Albuminuria ; 
General  Miliary  Tuberculosis ;  CEdema  of  legs. 

Signs  of  a  cavity  (vomica).  Percussion,  giving  a  metallic 
cracked-pot  sound  on  auscultation  ;  respiration  blowing, 
tubular,  cavernous,  with  moist  rales  at  apex.    Pectoriloquy. 


142  CLINICAL   MEDICINE   AND    CASE-TAKING, 


PNEUMONIA. 

Physical  signs. — Signs  of  Consolidation  over  hepatized  lung. 
Earliest  sign,  fine  inspiratory  crepitation  resembling  the 
rustling  of  hair  ;  there  may  be  also  a  pleuritic  friction. 
In  hepatization,  dulness  along  outline  of  the  lobe  solidified  ; 
if  at  base,  sloping  downwards  and  forwards.  T.V.F. 
usually  increased.  Respiration  tubular  and  often  accom- 
panied by  rhonchus  and  rales.  Voice  broncho-phonic. 
On  resolution  respiration  becomes  less  tubular ;  crepitation, 
loose  inspiratory  and  expiratory  ( =  redux  crepitation).  A 
return  of  the  friction  rub  may  be  heard. 


V^     Digestiwi. — Tongue  furred  ;    thirst ;  anorexia.     There  may  be 
I  vomiting,  diarrhoea,  Jaundice. 


Circulation. — Note  force  of  impulse  and  first  sound  of  heart. 
Characters  of  pulse. 

Nervous  system. — General  condition  of  Nervous  System;  sleep, 
restlessness.  Delirium. 

Urine. — Scanty,  with  excess  of  lithates  ;  chlorides  deficient. 
May  be  albuminous. 

Complications.  —  Pulmonary  oedema  ;  collateral  congestion. 
Bronchitis  ;  high  fever  ;  failure  of  heart,  pulse  becoming 
weak  and  soft.  Jaundice  ;  Delirium ;  Albuminuria  ; 
Typhoid  State, 


DISEASES    OF   THE   RESPIRATORY   SYSTEM.  liS 


PNEUMONIA. 


In  acute  cases  onset  sudden  with  rigor,  fever,  quick  breathing. 
Pleuritic  pain  and  dyspnoea  usually  subside  -^ith  the 
pyrexia,  and  coincidently  with  the  signs  of  hepatization. 
Cough  ;  expectoration  viscid,  golden  colour,  occasionally 
streaked  with  blood  ;  it  may  be  accompanied  by  aerated, 
frothy  bronchial  sputum.  N"ote  date  of  disease  ;  P.  =  ; 
T.  =  ;  R.  =  .  Pleuritic  pain  may  return  during  resolu- 
tion. Symptoms  usually  subside  by  crisis ;  dyspncea,  fever, 
disti-ess  passing  off  suddenly,  leaving  lung  hepatized  and 
patient  prostrated. 


Classes  ofPneuvionia. — Acute  sthenic  as  above  described :  usually 
at  base.  Asthenic  "odth  adynamic  symptoms :  less  sudden 
onset  and  no  marked  crisis  ;  less  distinctly  marked  signs  of 
solidification  ;  much  tendency  to  bronchitis  and  pulmonary 
cedema,  patient  tending  to  the  Typhoid  State.  ,  It  may  end 
in  Gangrene  of  Lung-. 


Pneumonia   of  the   apex.     Frequently   accompanied   by  grave 
nervous   disturbance,     and    long  convalescence   or   subse 
quent  phthisis. 


Causati&iu — Exposure  to  cold.  A  complication  of  fevers. 
Secondary  to  chronic  disease,  e.g.,  of  lungs  or  kidneys; 
rheumatism ;  injur}'- ;  adjacent  inflammation  or  disease, 
e.g.,  pneumonia,  cancer,  tubercle. 


\ 


144  CLINICAL   MEDICINE  AND    CASE-TAKING. 


EMPHYSEMA. 


Physical  sigris. — Chest  may  be  large  or  small ;  expansion  is 
markedly  diminished,  and  such  movement  as  there  may  be 
is  usually  vertical  without  forward  expansion.  Heart's 
impulse  more  or  less  encroached  upon,  and  marked  by 
lung  covering  it,  but  it  may  be  felt  as  somewhat  diffused. 
General  hyper-resonance  on  percussion.  Absolute  dulness 
over  heart  may  be  wanting  with  an  extended  area  of 
relative  dulness.  On  auscultation,  expiratory  sound  much 
prolonged ;  feeble  and  toneless,  harsh,  often  accompanied 
by  rhonchi  and  sibili.     Liver  may  be  depressed. 


Circulation, — Pulse  feeble  ;  right  ventricle  dilated  ;  heart  may 
be  hypertrophied.     Passive  Venous  Congestion. 


Urine. — May  be  scanty  and  albuminous.     Chronic   Granular 
Kidney  not  uncommonly  accompanies  emphysema. 


Causation. — Vicarious  dilatation,  e.g.,  adjacent  to  pulmonary 
collapse  or  consolidation,  or  cells  obstructed  by  bronchitis, 
Paroxysmal  cough  ;  laborious  work ;  Hooping  Cough ; 
heart  disease  ;  Alcohol ;  Gout  leading  to  ill-nourished 
condition  of  lungs.     Senile  changes. 


DISEASES   OF   THE    RESPIRATORY   SYSTEM.  145 


EMPHYSEMA. 


Lungs  lose  their  elasticity,  much  aerating  smface  is  lost,  and 
many  pulmonary  capillaries  destroyed,  thus  obstructing  the 
flow  from  the  right  ventricle.  Passive  venous  congestion 
results.  The  difficulty  of  expanding  lungs  with  diminished 
elasticity  throws  respu'atory  muscles  into  strong  action, 
and  the  sterno-mastoids  are  often  hypertrophied. 

The  patient  may  emaciate  or  grow  fat  ;  in  neither  case  is  nutri- 
tion good.  Usually  chronic  winter  cough  and  liability  to 
acute  bronchitis. 


Complications  and  accompaniments. — Heart  :  right  Ventricle 
Dilated  and  hypertrophied  ;  veins  large  ;  cyanosis  ;  Tri- 
cuspid Eegnrgitation.  (Edema  of  feet.  Bronchitis  due 
to  passive  congestion  of  bronchial  veins,  which  empty  their 
blood  into  the  right  heart.     Dyspnoea  on  exertion. 

Albuminuria  may  be  from  coexisting  Bright's  disease,  and  is 
then  usually  constant ;  if  albumen  be  due  to  renal  conges- 
tion it  may  pass  off  with  other  signs  of  congestion,  the 
albumen  lessening  and  the  quantity  of  urine  increasing. 

Cutaneous  capillaries  of  cheeks  often  enlarge. 


146  CLINICAL   MEDICINE   AND    CASE-TAKING. 


BRONCHITIS. 

Physical  signs. — If  bronchitis  is  secondary  to,  or  complicates 
other  disease  of  lungs,  the  signs  will  be  partly  those  of  that 

other  diseased  condition. 

Aiiscultaiion. — Often  gives  negative  results,  especially  iu 
chronic  winter  bronchitis.     E-honchi  ;  sibili  ;  rales. 

Palpation. — Rhonchi  are   sometimes   felt  by  the  hand 
especially  in  the  elastic  chests  of  infants.     Palpate  heart. 

Percussion. — Xo  change  from  the  normal,  or  temporary 
tonelessness  in  parts. 

Inspectimi. — Observe  chest  movements  ;  collapse  of  chest 
at  apices,  or  in  hj'pochondriac  regions.     Dyspnoea. 

Urine  may   be   albuminous,    a   similar  cause  producing 
Bright's  disease  and  bronchitis.     See  Albuminuria. 

Inquire  for—?.  =  ;  T.  =  ;  R.  =  ;  W.  =  .  Signs  of 
Consolidation  of  Lungs  ;  signs  of  contraction.  Cough ; 
Expectoration ;  Haemoptysis. 


ASTHMA. 

Respiration. — Percussion  unaltered  during  paroxysms  ;  shrill 
whistling  sibili.  Examine  lungs  during  paroxysms  and 
during  intervals.  The  paroxysms,  note  their  frequency 
and  duration,  exciting  and  predisposing  causes.  Cough  ; 
expectoration. 

Causation. — Hereditary  tendency  to  neurosis.  Reflex  causes, 
uterine,  constipation.  Tubercular  diathesis  ;  Emphysema ; 
Heart  Disease;  Uraemia.  May  occur  in  Bright's  disease 
without  other  signs  of  anaemia. 


DISEASES   OF   THE    RESPIRATORY   SYSTEM.  147 


BRONCHITIS. 

This  condition  may  be  acute  or  cki'onic  ;  primary  or  secondary 
to  other  disease,  e.g.,  Emphysema,  Phthisis,  Pneumonia, 
etc. 

It  is  characterized  by  cough,  "with  expectoration  usually  frothy 
and  watery,  sometimes  viscid  or  purulent  ;  dyspncea. 
Fever  usually  slight,  but  high  in  children.  Post-sternal 
pain  and  tenderness,  increased  on  coughing  ;  skin  over 
sternum  sometimes  sore. 

Causation. — Exposure  to  cold  ;  fevers  ;  bronchitis  secondary  to 
chronic  lung  conditions  ;  phthisis  ;  emphysema  secondary 
to  acute  conditions  ;  pneumonia  ;  pleurisy. 

Secondary  to  heart  disease  ;  Eickets  ;  mechanical  irritants. 

Course  of  disease  if  towards  fatal  termination. — Inability  to 
expectorate.  Rapid  respiration.  Pulse  becoming  weak, 
compressible,  irregular  ;  heart  distended  on  the  right  side  ; 
veins  prominent  ;  cyanosis.  (Edema  of  legs  increasing. 
Rales  all  over  lungs.  Sleeplessness.  Tendency  to  Coma 
and  the  Typhoid  State. 

Urine  scanty  and  albuminous.  Temperature  falling.  In 
children  collapse  of  chest  at  bases  with  infalling  of  epi- 
gastrium. 


ASTHMA. 

An  affection  characterized  by  paroxysms  of  dyspnoea. 

Paroxysms. — Orthopnoea  ;  respiratory  muscles,  ordinary  and 
extraordinary,  at  work.  Chest  fully  dilated  and  respi- 
ratory movement  almost  nil.  Sense  of  want  of  air.  Yoice 
weak  or  lost.  Onset  of  paroxysm  sudden,  subsidence  rapid  ; 
they  frequently  occur  at  night.  They  may  be  preceded  by 
drowsiness  and  a  sense  of  fatigue. 


14S  CLINICAL   MEDICINE   AND    CASE-TAKING. 


LARYNX,  DISEASE  OF. 

Acute  conditions. — Diphtheria,  croup,  catarrh,  oedema,  lar}m- 
gismus  stridulus. 

V 

Chronic  conditions. — Laryngitis  :  syphilitic,  strumous,  or  phthi- 
■  sical.     Hysteria.     Palsy  of  vocal  cords,  or  one  cord. 

General  condition. — P.  =  ;  T.  =  ;  R.  =  ;  W.  =  .  State 
of  nutrition  ;  signs  of  struma  or  Syphilis  ;  Rickets  ; 
Phthisis. 


Digestion. — Examine   mouth   and   fauces,    using  laryngeal  re- 
flector. 


Circulation.  — Examine  heart  as  to  strength  and  dilatation  of 
right  side  ;  venous  fulness  ;  strength  and  regularity  of 
pulse.     Seek  for  signs  of  Aneurism. 

Respiration. — Signs  of  laryngeal  disease  ;  laryngoscopic  appear- 
ances ;  movements  of  cords.  Bronchitis,  oedema  of  lungs, 
pneumonia,  etc.     Chest  movements.     Look  for  Phthisis. 

Xervous  system. — Signs  of  Convulsions,  thumb  turned  in  fist ; 
chronic  spasm  of  muscles  ;  hysteria.  Palsy  of  one  cord, 
usually  from  pressure  on  recurrent  nerve.     See  Aneurism. 

Urine  often  albuminous  in  diphtheria  ;  there  may  be  coincident 
acute  Bright's  disease. 


DISEASES   OF   THE   PwESPIKATOEY   SYSTEM.  149 


LARYNX,   DISEASE  OF. 

Signs  of  Laryngeal  disease. — Voice  husky  or  lost ;  stridulous 
inspiration,  aphonia,  cough,  dyspncea,  cyanosis.  Dila- 
tation of  right  side  of  heart,  and  other  signs  of  obstruction 
to  the  entrance  of  air,  e.g.,  infallingof  supra-sternal  notch, 
supra-clavicular  spaces,  and  epigastrium,  and  in  young 
children  collapse  of  the  hypochondriac  regions.  Tracheo- 
tomy may  be  required  when  this  obstruction  is  extreme  ; 
in  such  a  case  observe  the  condition  of  the  heart,  pulse,  and 
circulation  before  and  after  operation. 


Laryngismus  Stridulus. — Mostly  in  children  ;  spasmodic  crow 
ing  sound  on  inspiration,  child  being  well   in  intervals. 
Frequent  during  dentition,  in  Rickets,  and  associated  with 
general  Convulsions. 


(Edema  may  occur  during  Bright's  Disease,  Erysipelas,  etc., 
acute  catarrh  from  cold,  or  with  onset  of  Measles.  In 
Hysterical  Aphonia  cords  are  seen  healthy  but  motionless : 
pharynx  often  very  anaesthetic. 


Functional  Aphonia. 


150  CLINICAL    MEDICINE   AND    CASE-TAKING. 


DISEASES   OE   THE   DIGESTIVE   SYSTEM. 
SIGNS  OF  DIGESTIVE  FUNCTIONS. 

Ajwetite. — Good,  bad,  indifferent,  altogether  lost.  Frequency 
of  recurrence,  capricious  and  fanciful;  variable,  excessive, 
voracious.     Nausea.     Vomiting". 

Fulness  or  pain  after  food.  Enquire  how  soon  after  food  ;  its 
character  and  duration  ;  whether  pain  is  relieved  by- 
vomiting.  "Whether  pain  without  food.  Flatulence  and 
eructations. 

Eructations.     Heartburn.     "Water-brash.     Pyrosis, 

State  of  Bovjels. — Regular,  constipated,  relaxed,  with  or  with- 
out pain.  Diarrhoea ;  frequency  of  action.  If  disturbed 
see  and  describe  the  motions — solid,  liquid,  light,  clay- 
coloured,  dark,  black ;  hard  scybala,  flattened  or  tape-like, 
well  formed,  with  blood,  pus,  etc. 

INTESTINAL  WORMS. 

T(xnia  mediocanellata — beef  tapeworm. — The  head  is  at  the 
narrow  portion  of  the  worm  ;  it  has  four  sucking  discs, 
but  is  unarmed. 

Taenia  solium. — Less  common  in  England.  Pork  tapeworm  ; 
four  suckers  and  an  armed  head.  T.  Bothriocephalus 
latus.  They  live  in  small  and  large  intestines.  Thread 
worms — Oxyuridis — live  chiefly  in  rectum  ;  common  in 
children. 

Lumhricus,  round  worm.  Ascaris  lumbricoidis  lives  in  upper 
intestine,  and  may  be  vomited. 


DISEASES   OF   THE   DIGESTIVE   SYSTEM.  151 


SIGNS  OF  DIGESTIVE  FUNCTIONS. 

Appetite  increases  with  thirst  in  Diabetes.  Anorexia  (loss  of 
appetite)  and  thirst  in  Fever.  In  children  often  variable, 
especially  in  nervous  cases  ;  they  often  drink  much  in 
health,  when  urine  is  scanty  with  high  sp.  gr.  Appetite 
is  often  lost  in  functional  disturbance  of  the  nervous 
system,  e.g.,  over- work,  loss  of  sleep.  In  Hysteria  and 
insanity  the  appetite  may  be  greatly  perverted  ;  so  also 
during  pregnancy. 

State  of  Bowels. — Constipation  may  result  from  Plumbism, 
senile  atrophy  of  bowels,  inactive  habits  of  life,  ill- 
arranged  diet. 

Relaxation  or  looseness  from  Dysentery,  Tllceration  of  Bcwels, 

or  other  organic  condition.     In  infants  from  ill-feeding  or 
summer  heat. 


152  CLINICAL   MEDICINE   AND    CASE-TAKING. 


EXAMINATION  OF  THE  MOUTH  AND  THROAT. 

On  obtaining  a  good  view  of  all  parts  of  the  mouth,  see — 
tongue  ;  hard  and  soft  palate,  with  uvula  ;  pillars  of  the 
fauces,  anterior  and  posterior  ;  tonsils  ;  pharynx ;  the 
buccal  cavity  ;  cheeks  and  lips,  mucous  membrane  ;  gums  ; 
teeth. 

Tongue. — Mucous  membrane  and  condition  of  muscle.  In- 
dented at  edges  by  the  teeth  ;  flabby  ;  clean  or  coated  with 
far  ;  white,  yellow,  dirty,  dry,  or  moist.  Enlarged  papillae 
at  tip  projecting  through  far.  How  protruded  ;  straight 
or  deviating  to  one  side,  kept  well  out  and  steady,  or 
a  jerked,  tremulous,  distinct  muscular  tremor. 

Palate  and  Uvula. — High  arched  roof,  cleft.  Ulceration, 
destruction  of  soft  palate,  adhesions.  Movements  of  soft 
palate  and  fauces. 

# 

Tonsils. — Enlarged,  one  or  both.  Smooth,  pale  or  congested  ; 
"with  large  follicles.  Ulcers  superficial  or  deep,  if  sym- 
metrical.    Exudation  on  surface. 

Pharynx. — Mucous  membrane  and  movements.  Look  for  ulcers 
or  old  sears  and  adhesions.  Thrush  in  children ;  exuda- 
tion in  diphtheria. 

Teeth.. — Look  for  tender  teeth  ;  those  subjects  of  caries ;  see  if 
wisdom  teeth  be   cut.       Note   condition   as  to   dentition 

in  infants. 


Gums. — Whether  of  normal  substance  or  shrunken  ;  condition 
of  mucous  membrane. 


DISEASES   OF   THE   DIGESTIVE   SYSTEM.  153 


EXAMINATION  OF  THE  MOUTH  AND  THROAT. 

It  is  necessary  to  obtain  a  good  light  in  the  pharynx  ;  hence  it 
is  often  convenient  to  use  a  lamp  and  the  frontal  reflector 
of  laryngoscope.  There  may  be  signs  of  local  or  general 
disturbance. 


Tongue. — Flabby  and  coated  in  dyspepsia  ;  often  red  with 
Gastric  Ulcers  and  Cerebral  Vomiting.  Protruded  to  one 
side  in  Hemiplegia.  Tremulous  in  Alcoholism,  excessive 
smoking,  General  Paralysis  of  the  Insane.  Jerked  and 
twitching  in  Chorea.  Ulceration  from  local  irritation. 
Ulcer  of  frsenum  in  hooping  cough.  Syphilis.  Epi- 
thelioma. 

Palate  and  Uvula. — Palate  high,  arched,  flat,  cleft.  Ulcer- 
ation, scars,  adhesion  from  scrofulous  disease  or  Syphilis. 
Uvula  commonly  elongated.  Movements  of  palate  and 
uvula  affected  in  palsy  of  Nerve  YII. 

Tonsils. — Chronic  enlargement  in  rickets,  often  with  deafness. 
Ulcers  symmetrical  in  secondary  syphilis.  See  Quinsy, 
Diphtheria,  Syphilis. 

Pharynx. — Scars  from  syphilis  or  strumous  ulceration.  Paralysis 
from  diphtheria.  Epithelioma.  Post-pharyngeal  abscess 
from  spinal  caries. 

Teeth. — Upper  central  incisors  (of  second  dentition)  may  be 
dwarfed,  with  atrophy  of  the  middle  lobe  in  Inherited 
Syphilis.  Much  ground  in  gouty  people  and  children  who 
suffer  from  Headaches. 

Gums. — Blue  line  in  Plnmbism.  Spongy  in  mercurialism. 
Swollen  and  bleeding  in  scurvy.  Covered  with  sordes 
in  fever. 


15i  CLINICAL   MEDICINE   AND    CASE-TAKING. 


DIARRHCEA. 

K'ote  mode  of  onset  and  duration  ;  if  attended  with  pain, 
griping  ;  Melaena ;  tenesmus  (frequent  desire  to  evacuate 
the  bowels,  but  without  effect).  Whether  acute  with 
paroxysmal  griping,  melaena,  collapse,   as  in  cholera. 

Motions  passed. — Relaxed,  liquid,  pea-soup-like  ;  containing  bile 
or  not ;  scybala,  shreds  of  mucous  membrane,  undigested 
food,  worms. 


VOMITING. 

Note  the  frequency  of  vomiting  ;  whether  it  occurs  only  after 
food  ;  whether  giving  relief  to  symptoms ;  if  affected  by 
position.  State  of  tongue  and  bowels.  Examine  abdomen 
for  tenderness ;  signs  of  disease  of  stomach.  See  general 
condition  of  Nervous  System.  Signs  of  Brain  Disease. 
Examine  urine. 

Matters  vomited. — Food  unchanged;  bile-stained  fluid;  clear 
acid  fluid ;  yeast-like  matter  containing  sarcinae  seen 
on  microscopical  examination ;  blood  (hsematemesis)  ; 
dark  coffee-grounds-like  matter,  altered  blood ;  lumbrici. 
Faecal  matters  may  be  thrown  up  in  obstruction  of  bowels 
low  down. 


DISEASES    OF   THE   DIGESTIVE   SYSTEM.  155 


DIARRHCEA. 

May  be  indicative  of  local  disease  or  general  disturbance. 

Causation. — Disease  of  tbe  bowels;  Tubercular  TJlceration ; 
Amyloid  Disease ;  stricture  of  bowel,  rectum  ;  scybala  ; 
enteric  fever ;  Dysentery  ;  cbolera ;  erysipelas,  etc.  ; 
Bright' s  Disease;  ill-feeding;  Alcoliolisni ;  exposure  to 
heat  and  cold  ;  poisoning  ;  Rickets  ;  nervous  disturbance  ; 
Graves'  Disease.    Previous  constipation. 

VOMITING. 

May  indicate  local  or  general  disturbance  or  brain  disease.  See 
Cerebral  Vomiting. 

Causation. — 

Stortiach. — Gastritis  ;  dilatation  of  stomach. ;  catarrh 
secondary  to  Cirrhosis  of  the  Liver ;  irritating  food ; 
Alcoholism;  poisons;  Cancer;  Gastric  Ulcer ;  constriction 
of  pylorus  or  duodenum. 

Eeflex  causes. — Pregnancy;  ovarian  disease;  uterine 
disturbance  ;  dysmenorrhcea  ;  dentition ;  intestinal  worms ; 
Gall-stones ;  Eenal  Calculus ;  Addison's  Disease ;  liver 
disease,  cancer,  abscess,  etc.;  disturbance  of  special  senses, 
glaucoma,  ear  disease.  Attendant  on  paroxysms  of  hoop- 
ing cough. 

Brain  disease. — Headache;  Hysteria.  See  Cerebral 
Vomiting. 

Blood  conditions.— Ferer  ;  malaria  ;  Bright' s  Disease  ; 
Obstruction  of  Bowels;  Peritonitis. 


156  CLINICAL   MEDICINE   AND    CASE-TAKING. 


ACUTE  ABDOMINAL   PAIN. 

Enquire  as  to  digestive  functions  ;  previous   attacks  of  Biliary 

Colic,  Eenal  Colic,  gastric  ulcer. 
Examine  mouth  and  tongue  for  indications  of  Gastric  Ulcer, 

poisoning  ;  and  gums  for  Line  lead  line. 
Palpate  and  examine  abdomen  ;  note  if  tender  and  tympanitic  ; 

position   of  the   patient,  whether   still   and  prostrate   or 

moving  about.     In  females  look  for  signs  of  pregnancy, 

uterine  action,  or  haemorrhage. 
Examine  heart,  pulse,    skin,    pupils,   urine.      T.  =     .     Note 

if    much    collapsed ;    whether    able    to    speak ;    whether 

vomitincr. 


DYSPHAGIA. 

General  Condition. — Anaemia.  Signs  of  Cancer.  General  con- 
dition of  Nervous  System.   Syphilis.    Senile  degeneration. 

Digestion. — Examine  mouth  and  throat  for  ulceration,  scars, 
etc.  Auscultate  spine  while  patient  drinks,  looking  for 
gurgling  at  one  point.     Pass  oesophageal  bougie. 

Vascular  system. — Signs  of  disease  of  vessels  or  aneurism. 


H^MATEMESIS. 

Enquire  as  to  the  general  signs  of  the  Digestive  Functions, 
previous  vomiting,  pain,  tenderness,  etc.  See  causes  of 
Vomiting.  Examine  the  matters  vomited  and  the  motions 
as  to  htemon-hage,  etc.  Examine  the  abdomen  generally. 
Look  for  disease  of  stomach  and  liver.  Examine  lungs 
and  heart  to  detennine  absence  of  causes  of  hemoptysis. 
See  diagnosis  of  Haemoptysis  from  Haematemesis.  Urine. 
Anaemia.     Amenorrhcea. 


DISEASES    OF   THE   DIGESTIVE   SYSTEM.  157 


ACUTE    ABDOMINAL  PAIN. 

Causation. — Rupture  of  hollow  viscera,  stemach,  intestine, 
bladder.  Renal  or  Biliary  Calculus.  Irritant  poison. 
Over-feeding.  Colic,  simple  or  from  gout.  Plumbism, 
often  relieved  by  pressure.  Rupture  of  abdominal 
Aneurism,  abscess,  Hydatid.  Peritonitis.  Perihepatitis. 
Ulceration  of  bowels  with  peritonitis  or  perforation. 
Tubercular  Ulceration.  Acute  disease,  e.g.,  cholera. 
In  females  during  pregnancy,  concealed  accidental 
haemorrhage. 

Pain  and  tenderness  suggest  enteritis  or  peritonitis,  rather 
than  colic,  the  latter  being  often  relieved  by  pressure. 

DYSPHAGIA. 

Causation. — Tonsillitis ;  syphilitic  ulcerations ;  disease  of  larynx ; 
cancer  of  oesophagus  or  of  cardiac  end  of  the  stomach  ; 
thoracic  tumour ;  abscess,  post-pharyngeal  or  mediastinal  ; 
Aneurism ;  traumatic  injury  or  action  of  caustics  ;  ulcer  of 
stomach  at  cardiac  end  ;  Diphtheritic  Paralysis ;  Bulbar 
Paralysis. 

lu  General  Paralysis  of  the  Insane  there  is  much  tendency  to 
choking.     Hysterical  dysphagia. 


HiEMATEMESIS. 

Causation. — Gastric  Ulcer.  Corrosive  poisons.  Cancer  of 
Stomach.  Continued  vomiting  (reflex).  Acute  gastric 
catarrh.  lardaceous  Disease.  Pyloric  ulcer.  Bright' s 
Disease  ;  uraemia.  Passive  Congestion  of  stomach.  Scurvy. 
Cirrhosis  of  Liver.  Vicarious  menstruation.  Blood 
swallowed  and  vomited.  Patient  often  faints  from 
haemorrhage,  previous  to  the  discharge  of  the  blood  from 
the  mouth. 


158  CLINICAL   MEDICIXE   AND   CASE-TAKING. 


MELiENA. 

General  condition. — State  of  nutrition.     Anaemia  or  cacliexia. 

Digestion. — Examine  motions  ;  presence  of  abdominal  pain  or 
signs  of  gastric  disease,  pain  on  defaecation,  etc. 

Enquire  for  signs   of  Cancer ;    history   of  malaria  ;    previous 

diarrhcea  ;  signs  of  stricture  of  bowels. 
Examine  abdomen  ;  if  necessary  examine  rectum ;  urine  ;  lungs, 

as  to  signs  of  tubercular  disease. 


OBSTRUCTION   OF   THE  BOWELS. 

General  condition. — Position  of  patient  ;  pain  ;  abdominal 
tenderness ;  signs  of  collapse.  T.  =  .  Note  wlien 
bowels  last  acted. 


Digestion. — Habitual  condition  of  bowels,  regular,  costive,  or 
relaxed.  Previous  signs  of  disease,  e.g.,  Melaena,  Vomiting. 
State  of  tongue.     See  and  describe  the  motions  passed. 

Examine  abdomen,  especially  the  abdominal  rings,  and 
femoral  rings  for  hernia.  Note  fulness,  tenderness,  local 
swelling  or  tumour  ;  an  elongated  tumour  from  Intussuscep- 
tion. Signs  of  Peritonitis.  Track  out  colon,  if  distended, 
by  palpation  and  percussion.  Note  if  any  signs  of  con- 
traction at  any  point. 

Examine  rectum  with  the  finger,  or  give  enema  noting 
what  quantity  of  fluid  can  be  retained  ;  pass  the  long 
tube.  Sometimes  the  whole  hand  is  introduced  into  the 
rectum. 

Examine  per  vagiaajn. — Signs  of  pregnancy.  See  general 
sicrns  of  Cancer. 


DISEASES    OF   THE    DIGESTIVE   SYSTEM.  159 


MELJENA. 

May  be  caused  by  all  tbe  causes  of  Hsematemesis,  the  blood 
passing  from  the  stomacli  to  tbe  intestines.  Cirrhosis  of 
Liver,  or  other  obsti'uction  to  portal  circulation.  TJlceration 
of  Bowels,  tubercular.  Gastric  Ulcer.  Cancer  of  bowels. 
Enteric  Fever.  Dysentery.  Intussusception.  Pelvic 
hsematocele  or  abscess.  Piles  may  cause  bleeding  from  the 
anus.     Villous  growth  in  rectum.     Bright's  Disease. 


OBSTRUCTION   OF  THE   BOWELS. 

Causation. — I.  Compression. — Cancer  or  inflammatory  mass 
involving  intestine  ;  Abdominal  Tumour  ;  pregnant  uterus  ; 
ovarian  tumour  ;  pelvic  tumour  ;  uterine,  ovarian,  cellu- 
litis ;  retroverted  uterus. 

II.  Changes  in  wall  of  gut. — Cicatrization  of  intestinal 
ulcers,  dysenteric,  tubercular ;  congenital  deformity  of 
rectum,  etc.  ;  Cancer ;  epithelioma  and  syphilitic  disease 
of  rectum. 

III.  Strangulation. — Generally  in  small  intestine, 
hernia  ;  constriction  from  mesentery  of  portion  of  intes- 
tine drawn  into  a  hernial  sac  ;  or  from  bowels,  due  to 
peritonitis. 

IV.  Plugging. — Undigested  substances,  fruit  stones  and 
seeds,  hardened  fgeces,  masses  of  worms. 

Intussusception  ;  volvulus. 

Symptoms  vary  according  to  the  position  of  the  obstruction,  its 
degree,  its  cause,  the  complications.  If  in  small  intestines 
there  may  be  no  marked  and  characteristic  symptoms. 

The  motions  may  be  pipedike  or  not  formed.  Formed  motions 
may  be  produced  by  faeces  passing  the  stricture  and  being 
moulded  in  rectum.  Constipation ;  flatulence.  If  in 
rectum,  pain  and  straining  on  defsecation. 


160  CLINICAL   MEDICINE   AND    CASE-TAKING. 


GASTRIC  ULCER. 


Digestimi. — Pain  immediately  after  food,  relieved  only  by 
vomiting.  Water-brasli  vomiting.  HEematemesis.  Melaena. 
Inability  to  take  solid  food.  Localized  tenderness  at 
epigastrium  ;  no  tumour  felt.  Bowels  usually  confined  ; 
examine  the  motions.     Tongue  usually  red. 


JVote.  — General  condition  ;  position  of  patient ;  state  of  nutri- 
tion ;  signs  of  Ansemia.  General  condition  of  abdomen. 
Signs  of  Hysteria.  General  condition  of  the  Nervous 
System.     W.  =     .     Urine. 


TYPHLITIS. 


Local   examination  of  right   iliac    fossa.      Vaginal   or    rectal 
examination  to  determine  absence  of  pelvic  cellulitis. 

Causatimi. — Hardened  fseces  ;  undigested  food  ;  dysentery. 
Local  concretion  in  appendix.  Cherry  stone,  or  fish 
bone,  etc. 


DISEASES   OF   THE   DIGESTIVE   SYSTEM.  161 


GASTEIC  TJLCER. 


Pain  may  be  less  if  the  ulcer  is  on  the  lesser  curvature  of 
stomach.  In  long-lasting  cases,  some  thickening  of  walls 
of  stomach  may  be  felt,  or  stricture  of  the  pylorus  may 
result.  Usually  there  is  emaciation,  antemia,  or  cachectic 
appearance.  Menstruation  absent  or  disturbed.  Recovery 
may  occur  for  a  while  with  tendency  to  relapse  of  the 
symptoms,  or  perforation  and  Peritonitis,  vomiting, 
haemorrhage,  exhaustion. 

Causation. — Most  common  in  females  ;  specially  accompanies 
disordered  menstruation ;  may  result  from  action  of 
caustics. 

Complications. — Fistulous  communication  -udth  external  surface 
or  with  other  parts  of  intestines. 

Pyaemia. 


TYPHLITIS. 

Abdominal  pain  ;  local  signs  of  inflammation  in  the  right  iliac 
fossa,  pain,  tenderness,  swelling.  Local  peritonitis  with 
infiltration  of  the  cellular  tissue  ;  it  may  suppurate. 
Constitutional  disturbance  with  fever  may  be  considerable 
if  the  bowel  is  involved  ;  less  acute  if  only  around  the 
bowel.  Perforation  of  bowel  may  follow.  Usually  pain 
and  difficulty  in  moving  right  leg. 

M 


162  CLINICAL   MEDICINE   AND    CASE-TAKING. 


ABDOMINAL  CANCER. 


General      condition. — Note     state    of    nutrition,       W.    = 
Emaciation.      Pain   in   back,    exhaustion,    and   cachexia, 
Avith  the  general  signs  of  Cancer. 


Digestion. — Signs  of  digestive  functions.      Vomiting,  haemor- 
rhage, acid  secretions,  stomach  pain. 


Examine  abdomen. — Clear  out  bowels  A^ith  purgatives  or 
enemata  ;  empty  bladder.  Palpate  and  percuss  to  detect 
any  abdominal  tumour.  Note  any  signs  of  Obstructed 
Bowels  ;  Peritonitis ;  Ascites.  Examine  rectum  and  per 
vaginam  if  necessary. 


Cancer  of  Stomach, — A  mass  may  be  felt  in  epigastrium,  or  an 
increased  resistance,  often  most  distinct  along  greater 
curve  of  stomach.  A  rounded  and  movable  mass  may  be 
felt  over  the  pylorus. 

Cancer  of  Intestines. — A  mass  may  be  felt  on  palpation  ; 
it  may  be  movable.  Clear  out  bowels.  Inspect  and 
describe  the  motions,  whether  full-sized  or  flattened  and 
small.  Melaena.  If  there  is  obstruction,  or  arterial  haemor- 
rhage, examine  rectum  with  finger.     Look  for  piles. 


DISEASES   OF   THE   DIGESTIVE   SYSTEM.  163 


ABDOMINAL   CANCER. 


May  affect  stomacli,  intestines,  peritoneum,  mesenteric  glands, 
liver,  kidneys,  spleen,  uterus.  Secondary  deposits  in  tlie 
liver  are  common.     See  Abdominal  Tumour. 


Cancer  of  Stomach. — General  signs  of  cancer.  Pain  in  region 
of  stomacli,  a  very  varying  symptom.  Vomiting  acid 
frothy  matter,  often  with  sarcinee  ;  there  may  be  arterial 
Haematemesis  or  coffee-ground-like  matter.  Excessive  acid 
secretion.  Usually  it  is  primary.  Secondary  deposits  may 
occur  in  the  liver  ;  it  may  creep  on  to  pylorus  and  involve 
gall-duct.  Jaundice.  A  mass  may  thicken  the  pylorus 
causing  a  tumour  that  can  be  felt  there,  and  stricture 
with  vomiting  late  after  food.  Scirrhus  of  stomach  may 
run  its  course  through  many  years.  With  a  mass  that  can 
be  felt,  patient  may  still  gain  weight. 

Cancer  of  Intestines. — Usually  primary  ;  most  common  in  the 
sigmoid  flexure,  csecum,  and  rectum.  Abdominal  pain. 
Tendency  to  annular  contraction,  causing  Obstruction, 
May  be  mistaken  for  feecal  accumulations. 


Note. — Ulceration  of   rectum    may    be    from    epithelioma    oi 
Syphilis. 


164  CLINICAL   MEDICINE   AND   CASE-TAKING. 


ULCERATION   OF  BOWELS. 


Typhoid.    Cancer.    Epithelioma  at  anus.    Syphilis.    Ulceration 
from  gall-stones,  scybala,  intussusception,  etc. 


Dysentery. — Note    state    of    nutrition ;    Anaemia.      P.  =     ; 
T.  =     ;  R.  =     ;  W.  =     . 


Digestion. — Appetite.     Abdominal  pain  or  tenderness.    Evacua- 
tions:  colour,  consistence,  smell,  bile,  mucus,  or  sloughs. 


Liver. — Size,  absence  of  tenderness,  jaundice,  etc. 


Complications  and  Sequelce. — Chronic  dysentery.     Haemorrhage 

from  bowel.     Abscess  of  liver. 


Tubercular  Ulceration.  —  Getieral  condition.  —  Emaciation  ; 
excessive  sweating. 

Digestion. — Appetite.  Abdominal  condition  ;  fulness,  tender- 
ness, pain,  general  or  localized.  Bowels  relaxed  ;  may  be 
acting  with  pain  and  Melaena.     Enquii'e  for  fistula  in  ano. 

Eespiration. — Examine  lungs,  and  look  for  signs  of  Phthisis. 


DISEASES    OF   THE   DIGESTIVE   SYSTEM.  165 


ULCERATION   OF  BOWELS. 


Dysentery. — A  disease  more  common  in  the  tropics  than  here. 
Caused  by  malaria,  scorbutus,  bad  water,  salt  food,  etc. 
It  may  occur  in  an  acute  or  chronic  form.  It  is  febrile, 
characterized  by  tenesmus  with  the  passage  of  mucus 
without  fsecal  matter  or  bile  ,  sloughs  may  be  passed  with 
blood.  These  symptoms  depend  upon  inflammation  of 
the  colon  with  exudation  ;  it  may  extend  to  the  small 
intestine. 


Tubercular  Ulceration. — Common  in  cases  of  jjhthisis  and 
other  sti'umous  affections.  Abdominal  pain,  diarrhoea, 
and  melsena  may  result.  The  tubercular  ulcers  in  the 
bowels  are  transverse  ;  they  may  heal  up,  leading  to  scars, 
which  may  cause  stricture  of  the  bowels.  Ulcers  occur 
mostly  in  the  lower  part  of  the  ileum  and  caecum. 


Complications. — Peritonitis.     Ascites.     Perforation  of  bowels 
Acute  Miliary  Tuberculosis. 


166  CLINICAL   MEDICINE   AND    CASE-TAKING. 


ABDOMINAL   TITMOUIIS. 


General  condition. — State  of  nutrition.  "W.  =  .  Signs  of 
Cancer  or  Scrofulosis.  Abdominal  pain,  tenderness,  vomit- 
ing, condition  of  bowels,  signs  of  Obstruction,  Digestive 
functions.  Look  for  Ascites,  Peritonitis,  Abdominal 
Cancer,  oedema.     Urine. 

Examination  of  oJbdomen. — Palpate  and  percuss  abdomen  ;  tliiis 
endeavour  to  detect  any  tumour  present.  Define  its 
position  Tritb  regard  to  tlie  anatomical  regions  ;  determine 
its  boundaries  and  connections ;  particularly  note  if 
distinct  fi'om  liver  and  pehdc  organs.  Map  out  liver  and 
spleen,  showing  them  of  normal  size.  Xote  physical 
conditions  of  tumour,  its  size,  if  smooth,  rounded,  lobu- 
lated,  hard,  impressible,  doughy,  fluctuating.  If  mov- 
able or  moving  "Rdth  respiratory  movements.  Measure 
the  abdomen,  girth  at  base  of  chest  and  at  the  umbilicus, 
vertical  measurements  from  umbilicus  to  pelvis,  and 
umbilicus  to  xiphoid  cartilage.  In  the  normal  the  um- 
bilicus is  about  an  inch  nearer  to  the  pubes  than  to  the 
sternum.  Xote  pain  or  tenderness.  Empty  bowels  and 
bladder. 

History. — ^Commencing  on  one  side ;  enlarging  from  below 
upwards  ;  enlarging  of  the  abdomen  uniformly  ;  with  pain 
and  fever  or  not.  Did  symptoms  commence  at  a  menstrual 
period  ? 

Percuss,  palpate  liver,  define  and  mark  on  skin  the  vertical  and 
other  dimensions. 


DISEASES   OF   THE   DIGESTIVE   SYSTEM.  167" 


ABDOMINAL  TUMOURS, 


Ovarian.— 'Globular,  movable,  fluctuating ;  usually  situated 
more  to  one  flank  than  th.e  other.  Springing  from  the 
pelvis  and  may  be  felt  there.  Usually  dulness  in  centre  of 
abdomen  with  resonance  in  the  flanks.  If  very  large  may 
be  mistaken  for  ascites.  See  diagnosis  of  Ovarian  Tumour 
from  Ascites.  It  may  be  accompanied  by  ascites.  Dulness 
over  an  ovarian  tumour  shows  that  no  intestines  are 
in  front  of  it ;  so  also  with  a  pregnant  uterus. 

Kidney. — Colon  usually  passes  in  front  of  tumour  however  large 
it  becomes  ;  this  may  be  indicated  by  partial  and  varying 
resonance  over  it.  There  may  be  mixed  resonance  and 
dulness,  varying  on  different  occasions.  Tumour  may  be 
felt  in  the  flank,  usually  between  false  ribs  and  ilium  ;  a 
tumour  in  this  region  may  be  renal,  peri-nephritic,  fsecal  in 
colon.  Abscess  ;  cancer  ;  hydro-nephrosis  ;  blood-tumour. 
The  outline  is  rounded  or  lobulated  (cystic  tumour),  not 
easily  defined.     Absence  of  fluctuation. 

liver. — See  Large  Livers.  A  hepatic  tumour  descends  on  in- 
spiration.    Gall-bladder  ;  Hydatid;.  Cancer. 

Abdominal  Pulsation  common  in  hysterical  women  and 
dyspeptic  subjects.  Throbbing  of  abdominal  aorta  also 
common  in  emaciatioiL. 


168  CLINICAL   MEDICINE  AND   CASE-TAKING. 


FLUID  IN  peritoneum:. 


Physical  signs. — Enlargement  of  abdomen.  In  dorsal  position, 
dulness  on  percussion  over  tlie  fltiid,  which  gravitates  into 
the  flants  leaving  central  region  clear  ;  on  the  dependent 
side  of  abdomen,  a  distended  colon  may  give  a  tympanitic 
note,  but  on  palpation  in  this  flank  the  weight  of  the  fluid 
is  felt,  line  of  dulness  shifting  with  position.  Thrill 
transmitted  on  filliping  abdomen  ;  fluctuation.  When 
placed  on  hands  and  knees,  fluid  will  gra^atate  to  the 
umbilicus.  Clear  out  bowels  j  §mpty  bladder  ;  examine 
per  vaginam. 

Symptoms. — Dyspnoea  and  thoracic  breathing.  Pressure  on 
renal  veins  may  cause  scanty  urine  and  Albuminuria, 
Pressure  on  iliac  veins  causing  oedema  of  legs.  Superficial 
abdominal  veius  enlarged. 

Causation, — Cirrhosis  of  Liver,  Cardiac  disease.  Disease  of 
peritoneum,  tubercle,  cancer,  Peritonitis.  Exposure  to 
cold.     Ovarian  or  other  abdominal  tumour, 

CVjiditions  simulating  Ascites. — Ovarian  cyst.  Hydatid  cystic 
kidney.  Pregnant  uterus.  Distended  urinaiy  bladder, 
Eluid  in  intestines.     See  Abdominal  Tumours, 


DISEASES   OF   THE   DIGESTIVE   SYSTEM.  169 


ABDOMIKAI  TUMOUES, 


spleen. — Feel  for  the  notcli  toi;v'ards  anterior  margin.  Usually 
firm,  flat  superficial  under  abdominal  walls  without  intes- 
tine in  front.  Stretching  from  left  hypochondrium.  Sur- 
face may  be  lobulated  ;  it  may  be  tender  and  movable. 

Pancreas. — Has  been  stated  to  be  frequently  the  seat  of  cancer. 
Examine  fseces  for  fat ;  shake  up  with  ether. 

Causation. — Hypertrophy  ;  chronic  congestion  from  cardiac  or 
liver  disease  ;  Ague  ;  Amyloid  Disease ;  cancer.  Examine 
blood  for  leucocythaemia.  In  children  Rickets.  Syphilis. 
Large  sometimes  in  fevers,  specially  enteric.  Frequent 
seat  of  Embolism. 

Abdominal  Aneurism.— A  tumour  pulsating  and  laterally 
expansile,  with  a  thrill  and  systolic  bruit  often  also  heard 
over  spine.  Pain.  No  necessary  dyspeptic  symptoms. 
Pressure  signs  less  common  than  in  thorax  ;  it  may  press 
on  vena  cava,  or  cause  erosion  of  Vertebrae,  producing  great 
pain.  It  does  not  fall  forward  Avhen  patient  is  in  knee-elbow 
position.  A  tumour  lying  on  the  aorta  may  receive  a  com- 
municated impulse.  The  pulsating  aorta  without  disease 
may  often  be  felt  in  nervous  or  dyspeptic  patients,  especially 
in  females  if  emaciated.     See  Aneurism, 


170 


CLINICAL   MEDICIKE   AND    CASE-TAKING. 


Diagnosis  of 
OVARIAN   TUM0T7R        from 


ASCITES. 


Palpation. — Definite  margins 
may  be  felt.  Usually  situate 
more  in  one  side  of  abdomen 
than  in  the  other.  It  may  be 
traceable  into  the  pelvis  and 
felt  there. 

Percussion. — Dulness  in  cen- 
tral regiqn,  intestines  giving 
a  resonant  note  in  the  lumbar 
regions.  But  little  shifting 
of  dulness  on  alteration  of 
position  of  patient. 

Menmiration.  — Distance  of  um- 
bilicus from  sternum,  equal 
to  or  less  than  that  from  the 
pelvis.  Greatest  girth  below 
the  umbilicus- 

Piispection.  — Gen  eralroundness 
of  abdomen  ;  tumour  may  be 
seen  somewhat  rounded  and 
prominent. 


Fluctuation  may  be  de- 
tected ;  thrill  transmitted  in 
any  direction  on  filliping  the 
surface. 


Dulness  in  flanks ;  cen- 
tral region  tympanitic  as 
patient  lies  on  her  back,  and 

shifting    with    alteration    of 
position. 


Distance  between  umbilicus 
and  sternum  maintains  nor- 
mal ratio.  Greatest  girth  at 
umbilicus  or  above  it. 


Abdomen     flattened,     but 
prominent  and  broad. 


DISEASES   OF   THE   DIGESTIVE   SYSTEM.  171 


ABDOMINAL  TUMOURS. 


Tumours  ai-ising  from  the  j^^^'vis. — Examine  per  vaginam. 
Ovarian.     Perimetritis.     Pregnant  uterus. 

Inflamiiiatory  swellings. — Renal  or  perinephritic  abscess. 
Pelvic  cellulitis.  Parametritis  ;  towards  groins  and  iliac 
fossse. 

Fmcal  accumulations. — Usually  in  colon,  in  either  iliac  fossa. 
There  may  be  coincident  diarrhoea. 

Tubercular  mesenteric  glands. — Masses  may  be  felt.  Belly  large 

/and  tender,  emaciation,    diarrhoea.     Signs  of  Scrofulosis. 

Usually    coincident     signs    of    Tubercular  Peritonitis. 

Tympanites.      Ascites.      Abdominal    Cancer  may    cause 
enlarged  glands. 

Phantom  Tumour. — Arises  from  local  contraction  of  rectus 
muscle,  one  or  both.  It  may  be  dull  on  percussion,  and 
visibly  prominent ;  usually  it  occurs  in  the  lower  portion 
of  the  abdomen.  It  subsides  under  chloroform.  Not 
uncommon  in  Hysteria. 

Intussusception. — Cylindrical  tumour  produced  by  intus- 
suscepted  bow^el,  movable  from  day  to  day.  Tenesmus  ; 
passage  of  blood  and  mucus.  Signs  of  Obstruction  of 
Bowels. 


172  CLINICAL   MEDICINE   AND    CASE-TAKING. 


PERITONITIS. 


General  condition  of  po-tient.— Volition,  complaints  of  pain, 
state  of  skin,  tongue,  pulse.  Look  for  emaciation  or  other 
signs  of  chronic  disease.  T.  =  ;  R.  =  ;  P.  =  ;  W.  =  . 
See  Ascites ;  Abdominal  Tumour ;  Abdominal  Cancer  ; 
Acute  Abdominal  Pain ;    Hysteria.     Examine  abdomen. 


Causation. — Traumatic.  Rupture  of  bladder  or  other  \ascera. 
Ulceration  from  a  gall-stone,  etc.,  action  of  poisons, 
pressure  on  gut  from  hernia,  etc.  Exposure  to  eokl. 
-pyaemia.  Puerperal  fever.  Bright's  Disease.  Enteric 
fever.  Enteritis.  Cancer.  Tubercular  Ulceration  of 
Bowels.  Pelvic  inflammations.  Perityphlitis.  Abdominal 
Tumour. 


Diagnosis. — From   gastritis,   enteritis,    metritis,    cystitis,    and 
distension  of  bladder  ;  colic  ;  abdominal  hysteria. 


DISEASES    OF   THE   DIGESTIVE   SYSTEM.  173 


PERITONITIS. 


Acute  and  chronic.  Acute  cases  cliaracterized  by  abdominal 
pain  and  tenderness,  with  fever,  nausea,  vomiting,  con- 
stipation, abdominal  distension,  cold  sweats.  Patient 
usually  lies  on  his  back  with  the  legs  drawn  up  on  the 
abdomen;  collapse,  pulse  small  and  wiry,  skin  moist, 
extremities  cold.  Abdomen  distended  and  tympanitic. 
There  may  be  effusion  of  fluid.  Bowels  constipated. 
Respiration  shallow  and  thoracic.  Tubercular  peritonitis 
usually  occurs  in  young  scrofulous  subjects.  •  Masses  of 
glands  may  be  felt  in  abdomen. 


174  CLINICAL   MEDICINE   AND    CASE-TAKING. 

DISEASES  OF  THE  LIVER. 
JAUNDICE.* 

A. — Mechanical  Obstruction  of  Bile  Duct. 

I.  Obstruction  by  foreign  bodies  within  tlie  duct. 

II.  Obstruction  by  stricture  or  obliteration  of  the  duct. 

III.  Obstruction  by  Abdominal  Tumours  closing  the  orifice  of 
the  duct,  or  gi'owing  into  its  interior. 

B. — Jaundice  Indepeiident  of  Mechanical  Ohstrioction  of  the 
Bile  Duct. 

I.  Poisons   in   the   blood    interfering  with   chemical    changes 

in  bile. 

II.  Mineral  poisons. 

III.  Liver  diseases. 

IV.  Nervous  causes. 

Y.   Intestinal  accumulation. 

Jaundice. — Shade  and  depth  of  colour.  It  affects  also  urine, 
sebaceous  matter  and  sweat,  milk.  Taste  bitter.  Heart's 
action  slow.  Cerebral  depression  common  in  cases  depend- 
ent upon  obstruction,  and  when  there  is  no  obstruction 
tendency  to  stupor,  coma,  typhoid  state.  Skin  liable  to 
urticaria,  lichen,  boils,  vitiligoidea  ;  itchiness  of  skin  may 
precede  the  jaundice.  Digestion  disturbed,  constipation, 
flatulence,  emaciation.  In  chronic  hepatic  affections 
haemorrhages  are  common. 

*  See  Dr.  Murchison's  table:  "Diseases  of  the  Liver." 


DISEASES   OF  THE   LIVER,  175 

JAUNDICE. 

A. — Mechanical  Obstruction  of  Bile  Duct, 

I.  Gall-stones,  inspissated  bile,  foreign  bodies  from  intestines. 

II.  ia)  Catarrb  of  duodenum,  extending  from  gastric  catarrh. 
(&)  Congenital  defect,     (c)  Cicatrix  after  gall-stones, 

III.  Also  pressure  of  glands  of  transverse  fissm-e  of  liver, 
amyloid  or  cancerous.     Cancer  of  Liver. 

B. — Jaundice  Independent  of  Mechanical  Obstrudion  of  the 
Bile  Duct, 

I.  Relapsing  fever,  enteric,  typhus,  pyemia, 

II.  Phosphorus.     Metallic  poisons. 

III.  Acute  yellow  atrophy.  Congestion  of  liver  in  heart 
disease, 

lY.  Sudden  fright. 

V.  Chronic  constipation. 

Jaundice. — Colour  pale  sulphur,  lemon,  deep  olive.  As  it 
passes  off  skin  is  the  last  to  clear.  Urine  may  contain 
jaundiced  easts.  There  may  be  a  bitter  taste  from  bile 
acids. 

Diagnosis  from — 1,  Yellow  eye  due  to  subconjunctival  fat, 

2.  Addison's   Disease.     Here    discoloration    of   skin   is 
patchy  and   urine  is  normal, 

3.  Urine  blood-coloured  ;   may  resemble  jaundice,  but  is 
also  albuminous. 

4.  Infants  soon  after  birth  may  be  red  and  subsequently 
yellow,  suggesting  icterus  neonatorum. 

5.  Cachexia  from  Anaemia  or  malignant  disease. 


176  CLINICAL  MEDICINE   AND    CASE-TAKING. 


LARGE   LIVERS  * 

1.  Lardaceous.     Uniform  enlargement.     See  Amyloid  Degea- 
eration. 

2.  Fatty.     Uniform  enlargement. 

3.  Hydatid  tumour.     Bulging  or  projecting  from  liver. 

4.  Tight  lacing  may  cause  do%vnward  bulging  of  liver. 

5.  Congestion,  passive,  e.(/.,  from  heart  disease.     Enlargement 
uniform. 

6.  Catarrh  of  bile  ducts.     Enlargement  uniform. 

7.  Obstruction  of  common  duct,  e.g.,  sequent  to  Gall-stones. 

8.  Pysemic  abscess.     If  numerous,  enlargement  uniform. 

9.  Tropical  abscess,  causing  a  bulging  tumour. 

10.  Cancer,  if  secondary,  is  usually  diffused,  e.g.,  secondary  to 
■     cancer  of  sigmoid  flexure  or  stomach. 

Note  size  of  liver,  "whether  enlargement  be  uniform  or  irregular  ; 
whether  it  be  tender  ;  if  accompanied  by  Jaundice.     T.=   . 
Percuss  ;  palpate  and  map  out  the  liver. 

Normal  Liver  Dulness. — Commencing  posteriorly  about  the 
tenth  or  eleventh  dorsal  vertebra,  it  ascends  slightly 
towards  the  axilla  and  the  nipple,  then  again  descends 
gi'adually  towards  the  median  line  in  front.  In  median 
line  in  front  usuall}^  corresponds  with  the  base  of  the 
ensiform  cartilage,  and  to  the  left  of  this  blends  with  the 
cardiac  dulness  at  level  of  fifth  space.  In  right  mammary 
line  4 — 5  inches. 

Cancer  of  Liver. — General  condition,  see  Cancer,  signs  of.  Note 
if  jaundiced.  Liver  large ;  its  measurements,  outline, 
condition  of  surface  and  margin  ;  if  smooth,  rough, 
nodular  with  masses.  Xote  pain  or  tenderness.  Spleen 
rarely  enlarged.  Look  for  other  signs  of  Abdominal 
Cancer.    Ascites. 

♦  See  Dr.  Murchison, 


DISEASES   OF   THE   LITER.  177 

LARGE  LIVERS. 

1.  Firm,  smooth,  easily  felt  and  defined. 

2.  Less  definable  ;    there   may    be   general    fatty   growth   in 

the  body. 

3.  A  prominent  and  fluctuating  tumour  may  be  felt. 

4.  Tissue   of  liver    may   be   healthy,     and    symptoms    may 

be  absent. 

5.  Active  congestion  in  fevers  ;  frequent  in  tropical  climates. 

6.  Accompanied  by  signs  of  dyspepsia  and  jaundice. 

7.  External  pressure  on  duct  may  obstruct  it. 

8.  There  may  be  large  abscesses,  and  irregular  enlargement. 

9.  Usually  secondary  to  Dysentery. 

10.  Primary  cancer  usually  forms  a  mass  that  can  be  felt. 

Look  for — Anaemia.  Causes  capable  of  producing  Passive 
Congestion.  History  of  Alcoholism  or  residence  in  tropical 
climates.     Malaria. 

Cancer  of  Liver. — In  primary  cases  usually  cancerous  masses, 
or  large  nodules,  that  can  be  felt.  It  may  be  secondary 
to  other  abdominal  cancer  ;  then  usually  diffused  in  liver, 
enlarging  it  uniformly.  Such  deposits  occurring  may 
cause  vomiting. 

Diagnosis  from  —  Nodular  contractions  of  rectus  muscles  ; 
Amyloid  or  Cirrhosis  of  Liver ;  multiple  hydatid. 

N 


178  CLINICAL   MEDICINE   AND   CASE-TAKING. 


SMALL   LIVERS. 


1.   Simple   atrophy.      2.  Acute   yellow   atrophy.      3.  Chronic 
ati'ophy. 

1.  Simple     atl'ophy     occurs     in     senile     degeneration     and 

inanition. 

2.  Acute  Yellow  Atrophy. — General  condition  much  disturbed. 

History. — Habits,  especially  as  to  intemperance.  Syphilis. 
Pregnancies. 

Jjigcstion. — Anorexia  ;  vomiting  ;  tongue  fuiTed. 

Liver. — Xote  size  and  subsequent  diminution.  Jaundice,  with 
bile  in  feces. 

j\'ervoas  system.  —  Headache  ;  loss  of  muscular  power ; 
muscular  twitchings.  General  distmbance  of  Nervous 
System  tending  to  Coma. 

Urine. — Urea,  uric  acid,  and  salts  diminished.  Presence  of 
leucine  and  tyrosine,  products  of  metamorphosis  inter- 
mediate between  albumen  and  the  less  complex  nitrogenous 
(Compound,  urea. 

Cm'sation. — Alcoholism.  Syphilis.  Malaria.  Typhus.  Strong 
emotional  distui'bance.     Frequent  pregnancy. 


DISEASES   OF   THE   LIVEK.  179 


SMALL  LIVERS. 


1.  No  disease  and  no  change  of  structiu'e  of  the  tissue. 

2.  Acute  Yellow  Atrophy. — Liver  rapidly  decreasing  in  size  ; 

jaundice     without     obstruction  ;     symptoms     of     blood- 
poisoning. 

Fremonitory  symj)toms.  — Digestion  disturbed  ;  general  vague 
pains.     Jaundice  slight,  bile  still  appearing  in  fteces. 

Fully  established  disease.  —  Sets  in  with  sudden  onset  of 
symptoms  due  to  the  blood-poisoning,  depending  upon  the 
defective  formation  of  urea  and  uric  acid  ;  this  affects  the 
general  condition  of  the  patient.  Loss  of  strength. 
Jaundice  increases  ;  headache,  restlessness,  delirium, 
convulsions,  vomiting,  coma.  Typhoid  State.  Tongue 
dry  and  brown.  Hgemorrhages  in  skin  and  mucous 
membranes  may  occur.  Liver  dulness  constantly  and 
rapidly  diminishes.     Spleen  may  enlarge. 


180  CLINICAL  MEDICINE   AND    CASE-TAKING. 


CIRRHOSIS   OF  LIVER. 


GeneraJ  condition. — Anaemia;  emaciation;  sallownes3  ;  epistaxis; 
Ascites. 


Digestion. — Dyspepsia  ;  flatulence  ;  vomiting  ;  piles. 

Spleen. — Often  large. 

Liver. — Usually  small,  but  it  may  be  enlarged  in  early  stage  ; 
edge  and  surface  rough,  h.ob-nailed,  hard.  Jaundice  may 
be  present ;  then  it  is  slight.  Subsequently  liver  con- 
tracts.    If  there  be  peri-hepatitis,  liver  is  tender. 


SYPHILITIC  DISEASE  OF  LIVER. 


Gummata  may  be  felt  on  palpation.  Liver  may  be  tender 
from  peri-hepatitis  ;  lobulated  from  irregular  contraction, 
producing  a  notched  margin.     See  signs  of  Syphilis. 


DISEASES   OF  THE  LIVER.  181 


CIRRHOSIS   OF  LIVER. 


A  chronic  disease,  mostly  caused  by  chronic  Alcoholism. 
Dyspeptic  symptoms,  subsequently  Ascites  or  Haema- 
temesis.  Often  associated  Avith  Emphysema  and  Granular 
Kidneys. 

Spleen  large  from  obstruction  to  the  return  of  its  venous 
blood. 


SYPHILITIC  DISEASE  OF  LIVER. 


May  result  from  inherited  or  acquired  disease.  There  may  be 
gummata,  a  general  change  throughout  the  liver,  or 
peri-hepatitis. 


182  CLINICAL   MEDICINE   AND    CASE-TAKING. 


GALL-STONES. 


Occasionally  they  may  be  felt  on  palpation,  or  heard  on 
auscultation.  There  may  be  pain  on  jolting  or  any 
sudden  movement.  They  are  common  with  cancer  of 
gall-bladder.  A  stone  may  cause  obstruction  of  the 
common  duct  and  Jaundice.  There  may  be  recurrent 
attacks  of  biliary  colic.  Ulceration  of  gall-bladder  may 
result,  and  extend  to  neighbouring  organs,  causing  per- 
.  foration  of  any  of  the  hollow  viscera. 


BILIARY  COLIC. 


Attacks  of  severe  Abdominal  Pain,  due  to  passage  of  a  gall- 
stone from  the  gall-bladder  to  the  duodenum.  The 
attacks  usually  set  in  suddenly  after  exertion,  and  ma}' 
subside  suddenly,  and  be  followed  by  jaundice.  Attacks 
are  apt  to  recur  if  there  be  many  stones  present. 


DISEASES   OF   THE   LIVER,  183 


HYDATID    OF  LIVER. 


A  chronic  tumour  causing  an  irregular  outline  to  the  liver  ; 
usually  painless,  unless  it  be  inflamed.  It  may  be  of 
any  size  ;  is  usually  rounded,  firm,  slightly  fluctuating. 
If  there  be  no  adhesion  it  is  depressed  on  deep  inspira- 
tion ;  not  accompanied  by  jaundice  unless  there  be  some 
complication.  Usually  single,  but  there  may  be  many  in 
the  liver. 

Diagnosis  from  —  Cancer  ;  gummata  or  syphilitic  liver  witli 
irregular  contractions ;  abscess  of  the  liver  ;  distended 
gall-bladder ;  cystic  tumour  of  kidney ;  ascites.  See 
Abdominal  Tumours.  The  spleen  is  not  enlarged,  as  in 
some  other  conditions. 


Course  of  disease. — The  hydatid  may  suppurate  and  burst  into 
the  abdomen,  lungs,  pleura,  etc.  ;  it  may  form  adhesions  ; 
it  may  shrink  up. 

Fluid  in  cyst.  —  Often  removed  by  aspiration.  It  is  not 
albuminous  if  there  has  been  no  inflammation.  Sp. 
gr.,  about  1005  ;  chlorides  abundant.  Microscopically, 
small  cysts,  with  secondary  cysts  inside,  may  be  seen  ; 
"heads,"  separate  booklets.  Highly  refractive  particles. 
Cholesterin  may  be  found  in  fluid. 


184  CLINICAL   MEDICINE   AND    CASE-TAKING. 


DISEASES    OF   THE   URINARY    SYSTEM. 


BRIGHT'S  DISEASE. 


General  debility.  Anaemia.  Dyspepsia.  (Edema  or  anasarca. 
Necessity  to  urinate  frequently.  Skin  dry ;  often  unable 
to  perspire.     TTraemia. 

Digestion.  —  Dyspepsia  ;  Vomiting ;  diarrhoea  ;  Haematemesis ; 
melsena. 

Vascular  system.  —  Hypertrophy  of  Heart ;  bigh.  tension  of 
pulse  ;  arteries  tliickened  and  bard  ;  capillaries  dilated  on 
cbeeks.  Liability  to  baemorrbages,  epistaxis,  bsemoptysis, 
etc.     Excited  action  of  the  heart  in  ursemia. 

Nervous  system.  —  Disturbance  of  the  general  condition  of 
Nervous  System;  Vomiting,  Headache,  Vertigo,  etc. 
Retinitis  albuminuiica.     See  Uraemia,  Convulsions. 

Uriiu. — Albuminuria  almost  always  present  in  Brigbt's  disease. 
Quantity  altered,  usually  diminished.  Sp.  gi\  low  ;  the 
total  of  urea  excreted  diminished.  Casts  :  fatty,  hyaline, 
larger,  small,  epithelial,  granular.  Apparent  absence  of 
casts  not  an  absolute  proof  of  absence  of  Brigbt's  disease, 
but  evidence  in  that  direction. 


DISEASES   OF   THE   UEINAEY   SYSTEM.  185 


BRIGHT' S  DISEASE. 


The  name  signifies  disease  of  tlie  kidneys  accompanied  by 
Albuminuria,  and  dependent  upon  structural  changes. 
The  disease  is  usually  unattended  with  pain,  or  any 
subjective  symptoms  characteristic  of  the  disease.  Pallor 
of  the  face  is  often  a  marked  sign,  and  in  elderly  people 
is  often  suggestive  of  albuminuria.  Attention  must 
always  be  given  in  taking  the  history,  and  in  observing, 
to  determine  if  the  disease  be  Acute  or  Chronic. 


Vascular  system. — May  be  profoundly  altered  and  disturbed,  as 
indicated  on  the  other  page,  the  blood  changes  being 
shown  by  anaemia,  tendency  to  haemorrhages,  secondary 
inflammations,  etc. 

Causation.  —  Exanthemata,  specially  scarlet  fever  ;  febrile 
conditions,  e.g.,  pneumonia,  rheumatic  fever,  ague,  ery- 
sipelas ;  Alcoholism ;  exposure  to  cold ;  wet  and  cold 
work  ;  repeated  pregnancies  ;  dyspepsia  ;  Gout. 

It  is  of  great  importance  to  determine  whether  the  disease  is 
acute  or  chronic. 

ComplicatioTis. — Inflammatory  conditions  ;  Pericarditis ;  Pleu- 
risy ;  Pneumonia.  Cerebral  haemorrhage  ;  haemorrhages 
from  mucous  membranes.     Epistaxis.     Uraemia. 


186  CLINICAL   MEDICINE   AND    CASE-TAKING. 


UREMIA. 


General  condition. — Anasarca.  Ansemia.  Skin  liarsli  and  dry. 
Look  for  signs  of  Contracted  Kidneys. 

Nervous  system. — Head  Pain;  drowsiness;  Delirium;  Coma; 
temporary  blindness  ;  retinitis  albuminurica  ;  neuro- 
retinitis  ;  Typhoid  State  ;  muscular  twitchings  ;  Convul- 
sions. 

Vascular  system. — Liability  to  hgemorrhages  from  mucous 
membranes,  e.g.,  epistaxis,  Haemoptysis;  Hypertrophy  of 
Heart,  pulse  hard.  Pulse  often  strong  till  death  is  at 
hand. 

Digestive  system. — Dyspepsia;  Diarrhoea;  Vomiting. 

Respiratory  system. — Breath  smelling  ammoniacal ;  paroxysmal 
dyspncea,  resembling  asthma. 

Urine. — Quantity  ;  albuminous  ;  sp.  gr.  low  ;  deficient  in  urea 
and  salts  ;  Heematuria.     Casts  in  deposit. 

Gausatio7i. — Bright's  disease,  acute  or  chronic.  Suppression  of 
urine  from  obstruction  of  ureters.  Obstruction  to  renal 
veins  or  arteries.  Destruction  of  one  or  both  kidneys  by 
abscess,  calculi,  etc.  Cystic  kidneys  ;  surgical  kidneys, 
sequent  to  stricture  and  pyelitis. 


DISEASES   OF   THE   UEINARY   SYSTEM.  187 


UIliEMIA. 


Many  of  these  signs  may  be  met  with  without  urfemia. 
Inflammatory  complications,  e.g.,  Pericarditis,  Pleurisy. 
Dropsical  complications,  Hydrothorax,  hydropericar- 
dium,  Ascites.  Ursemia  is  a  condition  of  blood-poisoning; 
the  breath  becomes  ammoniacal,  and  the  excretion  of  urea 
is  much  diminished.  Diarrhoea  or  vomiting  may  lead 
to  a  favourable  termination.  The  skin  seldom  acts 
spontaneously,  but  its  action  is  favourable.  Symptoms 
may  set  in  gradually  or  suddenly,  with  convulsions. 
Progress  may  be  towards  recovery,  especially  in  acute 
Bright' s  disease ;  it  frequently  ends  in  death.  Relapses 
and  the  recurrence  of  symptoms  are  common.  Pulse  full, 
strong,  hard ;  heart's  impulse  strong. 

Urine. — Scanty  or  suppressed  from  Bright's  disease.  Passive 
Congestion  of  kidneys,  or  pressure  upon  renal  vessels,  etc. 

Causation. — Ureters  may  be  obstructed  by  calculi  or  pressed 
upon  by  pelvic  tumour,  e.g.,  ovarian.  Venous  congestion 
may  result  from  heart  disease,  Emphysema,  etc.  Renal 
arteries  may  be  obstructed  by  embolism  or  pressure  on 
arteries  by  an  Abdominal  Tumour. 


188  CLINICAL   MEDICINE   AND   CASE-TAKING. 


ALBUMINURIA. 


Causation. — Bright' s    Disease.      Passive    Congestion    of    the 

kidneys.  Simple  or  latent  albuminuria.*  Albuminuria 
from  fevers.  Calculous  disease,  due  to  presence  of  pus  or 
blood  in  urine.  In  females  from  leucorrhoeal  discharge, 
etc. ,  or  menstruation. 


Passive  {mechanical)  congestion. — Heart  Disease  or  Emphysema, 
etc.,  may  produce  over-fulness  of  vena  cava,  and  con- 
gestion of  the  kidneys.  Pressure  on  the  renal  veins  may 
also  prevent  return  of  blood  from  kidneys,  and  be  due 
to  pressure  of  a  pregnant  uterus  or  Abdominal  Tumour. 
Ascites  pressing  on  renal  veins. 


Urine. — Sp.  gr.  ;  quantity.  Albumen,  its  quantity  and 
variability  under  circumstances.  Deposit,  casts,  crystals, 
blood  discs,  epithelium.     Reaction. 


LooTc  for — Signs    of   Bright's    Disease.     Heart    disease    and 
Diseased    Vessels.     Emphysema  and  other  lung  disease 
Causes  of  passive  congestion. 


*  Dr.  Geo.  Johnson  :  "Brit.  Med.  Journ."  Dec.  13,  1879. 


.DISEASES   OF   THE   URINARY   SYSTEM.  189 


ALBUMINURIA. 


Passive  congestion  of  the  kidney s. — Then  the  amount  of  albu- 
men tends  to  vary  with  the  other  signs  of  passive  conges- 
tion, e.g.,  ascites,  jaundice,  oedema  of  legs,  etc.  No  history 
of  Bright's  disease  previous  to  the  cause  of  congestion. 
Albumen  less  abundant  and  casts  but  scanty  if  Bright's 
disease  is  absent.  Urine  of  high  sp.  gr.,  scanty  in  quantity, 
a  few  granular  casts. 


Simple  Albuminuria,  i.e.,  not  dependent  upon  Bright's  disease. 
— Urine  albuminous  without  any  marked  sti'uctural  lesion. 
May  be  due  to  exposure  to  cold  ;  excess  of  nitrogenous 
food.  Often  accompanied  by  oxalates.  During  fevers 
and  febrile  conditions,  e.g.,  typhus,  enteric,  cholera, 
diphtheria,  pneumonia,  rheumatic  fever.  But  few  casts, 
if  any. 


190  CLINICAL   MEDICINE   AND    CASE-TAKING. 


HJEMATITRIA. 


Causatio7i. — Disease  in  renal  tissue,  pelvis  of  kidney,  ureter, 
bladder,  urethra.  Bright's  Disease,  acute  or  chronic. 
Passive  congestion  of  kidneys.  See  Passive  (Cardiac)  Con- 
gestion. Active  congestion  of  kidneys  from  alcohol,  tur- 
pentine, cantharides.  Traumatic  injury.  Stone.  See  Renal 
Calculus.  Bladder,  Disease  of:  cystitis,  stone,  cancer, 
villous  growth,  etc.  In  females  during  menstrual  period. 
Paroxysmal  Hsematuria. 

Uriiie. — Albuminous,  alkaline,  smoky,  blood-coloured,  porter- 
like. Containing  heematin,  but  no  corpuscles.  See  if  in 
subsequent  course  albumen  occurs  without  blood.  Note 
the  colour  in  relation  to  the  amount  of  albumen  and  sp.  gr. 

Dejjosit. — Lithates  with  high  sp.  gi\  from  renal  con- 
gestion. Blood  casts ;  renal  casts  ;  epithelial  and  hyaline 
casts  in  Bright's  disease  ;  granular  and  hyaline  in  renal 
congestion.     Crystals. 

JBlood  may  be  mixed  with  the  urine  ;  in  clots  ;  in  clots  moulded 
in  ureter. 

Note  quantity  of  urine,  and  any  difficulty  in  micturition. 


DISEASES   OF   THE   URINARY   SYSTEM.  191 


HiEMATTJRIA. 


If  blood  comes  from  the  renal  structure  usually  there  are  blood- 
casts  and  smoky  urine  ;  if  from  the  urinary  passages  no 
casts  ;  if  from  the  bladder  or  urethra  pm-e  blood  and  clots 
may  be  passed,  usually  after  micturition.  Periodical 
attacks  of  discharge  of  porter-like  urine,  with  granules  and 
hyaline  casts,  and  the  deposit  of  brownish  granular  matter 
in  place  of  corpuscles.  See  paroxysmal  hematuria.  Hsema- 
tmia  may  appear  in  early  inflammation,  and  in  acute  exa- 
cerbations. Occasionally  late  in  cirrhosis.  Rare  in  lardaceous 
disease. 


Paroxysmal  Hsematuria. — At  irregular  intervals  sudden  attacks 
of  rigors,  the  next  urine  passed  being  loaded  with  blood. 
Health  may  long  continue  good.  The  paroxysms  are  un- 
attended with  pain  ;  there  may  be  a  feeling  of  chilliness 
across  the  loins,  weakness,  nausea,  vomiting,  joint-pain. 
The  patient  becomes  languid,  Aveak,  anaemic.  See 
Anaemia.  Examine  heart  and  vascular  system.  Optic 
discs.  See  Haematuria,  with  description  of  urine  ;  Eenal 
Calculus.  / 


Causation. — It  is  independent  of  any  known  structural  change 
in  the  kidneys.  Supposed  to  be  connected  with  ague, 
rheumatism,  exposure  to  cold  ;  certainly  such  exposure 
may  excite  the  paroxysms.  It  almost  always  occurs  in 
males,  usually  adults.     There  is  sometimes  oxaluria. 


192  CLINICAL   MEDICINE  AND    CASE-TAKING. 

BRIGHT'S   DISEASE,   ACUTE. 

-  Sigiis  a'od  symptoms. — Anasarca.  Suppression  of  urine,  more 
or  less  complete.  Skin  harsh.  Tendency  to  somnolence, 
head-pain,  vomiting,  coma.  Uraemia.  Usually  after  ex- 
posure to  cold  or  scarlet  fever.  It  may  resolve  or  terminate 
in  a  large  white  kidney. 
Uri'ive. — Smoky  ;     very  albuminous  ;     blood   discs    and   large 

I  epithelial  casts  abundant.     In   quantity,    scanty.     Blood 

"casts. 

GRANULAR  CONTRACTED   KIDNEYS. 

Signs  and  symptoms. — If  any  oedema  it  is  slight  and  transient. 
Heart  hypertrophied  ;  pulse  of  high  tension.  Liability 
to  epistaxis  and  hgemorrhages  from  mucous  membranes. 
Albuminuric  retinitis.  Tendency  to  uraemia.  Commonest 
in  advanced  life.  Often  there  is  coincident  cirrhosis  of  the 
liver. 

Urine. — Clear,  with  little  deposit  ;  quantity  large  ;  albumen,  a 
trace.     Small  granular  and  hyaline  casts.     Sp.  gr.  low. 

FATTY  KIDNEYS. 

Signs  and  symptoms, — Usually  anasarca.     Face  pale  and  puffy. 

Has   a   fatal  tendency.     May  result  from  acute  Bright's 

disease.     Not  uncommon  in  phthisis. 
Urine. — Fairly  copious  ;   albumen  much.     Fatty   casts  ;  fatty 

cells.     Sp.  gi\  rather  low. 

AMYLOID   KIDNEYS. 

Sig7is  and  symptoms. — Anasarca  moderate.     Pasty  anaemic  look. 

Emaciation  and  signs  of  amyloid  disease  of  other  organs  : 

spleen,  liver,  intestines. 
Urine. — Urine  copious.     Sp.  gr.   various.     Much  albumen  ;  a 

few  hyaline  casts. 

LARGE  WHITE  KIDNEYS. 

Signs  and  symptoms.  — Anasarca.  Ansemia.  Results  from  acute 
Bright's  disease.  Liability  to  intercurrent  acute  attacks, 
with  increase  of  the  symptoms. 

Z7ri7i€.— Scanty  ;  pale.  Casts,  hyaline  or  granular.  During 
exacerbations  blood  in  urine.     Albumen. 


DISEASES    OF   THE   URINAET   SYSTEM.  193 

BRIGHT'S  DISEASE,   ACUTE. 

Kidney  enlarged  and  congested,  the  wliole  structure  of  tlie 
organ  being  involved.  Cortex  much  swollen  ;  pyramids 
very  dark  and  congested  ;  glomeruli  large  and  congested. 
Epithelium  swollen  and  cloudy.  Veins  of  the  surface 
dilated. 


GRANULAR  CONTRACTED  KIDNEYS. 

Kidney  small ;  capsule  adherent ;  surface  gTanular  and  reddish. 
Frequent  cysts  in  cortex.  Much  wasting  of  cortex. 
Arteries  thickened. 


FATTY  KIDNEYS. 

Kidney  large,  yellow,  pale,  soft,  easily  broken  down. 


AMYLOID  KIDNEYS. 

Kidney    large    and    pale ;    surface    smooth  ;    cortex    thick ; 
glomeruli  and  vessels  stain  with  iodine. 


LARGE  WHITE  KIDNEYS. 

Kidney  large,  smooth,  white.  Cortex  much  swollen  from  over- 
development of  epithelium  in  convoluted  tubes  ;  but 
little  change  in  Malpighian  tufts. 


194 


CLINICAL   MEDICINE    AND    CASE-TAKING. 


BRIGHT'S  DISEASE. 


ACUTE, 


CHRONIC. 


Causation. — Cold.  Scarletfever. 


Anasarca.  — Present. 


Heart  and  2^ulse. — No  hyper- 
trophy. There  may  be  pal- 
pitation in  uraemia. 

OpJithaJmoscojrlc  aiojjearances.  — 
Usually  no  changes. 

Urine. — Smoky  colour.  Casts, 
with  large  granular  epithe- 
lium and  blood. 


Alcoholism.  Gout.  Senile 
degeneration. 

Present  with  fatty,  amy- 
loid, and  large  white  kidney  ; 
usually  absent  with  granular 
kidney. 

Hyj)ertrophy  ;  pulse  hard. 


May  be  haemorrhages  or 
retinitis  albuminurica. 

Hyaline  casts,  large  and 
small  ;  granular  casts  ;  fatty 
casts. 


Duration    of    albuminuria.  —  Many  months. 

Short  period. 


DISEASES   OF   THE   URINARY   SYSTEM.  '  195 


BLADDER,   DISEASES  OF. 


Disease  of  the  bladder  and  genito-minary  excretory  apparatus 
may  be  indicated  by — 

1 .  Urine,  — Thick,  with  deposit  of  mucus,  pus,  phosphates, 
blood,  etc. ;  reaction  alkaline  ;  smell  offensive.  Such  urine 
is  passed  with  cystitis. 

2.  Micturition  clijfficvU. — This  may  be  from  stricture  of 
the  urethra,  a  bladder  paralysed  with  retention,  or  over- 
flow, or  complete  incontinence.  This  may  arise  fi'om 
disease  of  the  Spinal  Cord  or  Brain  Disease,  Meningitis, 
or  Hysteria. 

3.  Hypogastric  pain  and  tenderness  with  fever. 

Cystitis  may  be  acute  or  chronic.  It  may  result  from  paralysis 
or  atony  of  the  bladder,  calculus,  cancer,  villous  growth. 
Much  mucus  renders  the  urine  alkaline  by  causing  the 
breaking  up  of  the  urea  into  ammonia  salts  ;  phosphates 
are  then  precipitated.  Cystitis  is  a  common  and  grave 
complication  of  Disease  of  the  Cord ;  in  such  cases  it  is 
usually  painless. 


196"  CLINICAL  MEDICINE  AND  CASE-TAKING. 


RENAL  CALCULUS. 


A  clironic  condition  ;  liability  to  acute  attacks. 

Chronic  course. — Aching  continuous  pain  in  one  lumbar  region, 
shooting  downwards.  Occasional  passage  of  blood-stained 
urine,  pus,  gravel,  epithelial  debris.  Hsematuria,  especially- 
after  jolting  exercise.  There  may  be  tenderness  in  the 
loin.  Occasional  attacks  of  renal  colic.  Bladder  :  there 
may  be  signs  of  stone  in  the  bladder,  or  Cystitis. 

Enquire  for  history  of  attacks  of  renal  colic,  Gout,  Uraemia, 
signs  of  disease  of  bladder. 

Complications. — Stone  in  the  bladder.  Nephritic  or  peri- 
nephritic  abscess.  Suppression  of  urine  from  impaction  of 
calculus  in  ureter  on  each  side. 

Urine. — Quantity. 


DISEASES   OF   THE   URINARY   SYSTEM  197 


RENAL    CALCULUS. 


Urine. — Varying  on  different  occasions.  It  may  be  mixed 
with  blood,  usually  not  forming  clots.  Albuminuria 
usually  proportioned  to  the  amount  of  blood  unless  the 
kidneys  are  degenerated  ;  then  albuminuria  may  occur  in 
degree  over  and  above  the  albumen  due  to  the  blood. 
There  may  be  crystals  of  oxalates  or  uric  acid,  etc. 
Usually  no  casts. 


Renal  Colic. — Attacks  may  come  on  without  any  previous 
symptoms  of  calculus.  In  the  attack  paroxysmal  j)ain 
in  one  lumbar  region,  severe,  causing  collapse,  vomiting, 
and  sometimes  suppression  of  urine.  The  attack  may 
cease  suddenly ;  then  the  next  urine  passed  may  be 
bloody,  and  may  bring  away  the  calculus  per  urethram. 
Such  paroxysms  especially  occur  after  exertion  ;  they  may 
last  days  or  weeks.  There  is  often  retraction  of  the  tes- 
ticle on  the  side  of  pain  (irritation  of  the  genito-crm'al 
nerve)  ;  the  pain  shoots  down  the  inner  side  of  the  thigh, 
and  is  accompanied  by  frequent  desire  to  micturate. 


198  CLINICAL   MEDICINE   AND   CASE-TAKING. 


TJIIINE,   DESCRIPTION   OF. 

Quantity. — In  healthy  adult  forty  to  sixty  ounces  per  diem. 

Colour. — Light   or  dark    sherry  ;    colourless  ;   smoky  ;    blood- 
coloured. 

Reaction. — Acid  (normal) ;  neutral  ;  alkaline. 

S2).  grr.— Normal,  1015—1025. 

Urea. — Normal,   400 — 600  grains  per  diem;  1'5  per  cent.  tt> 
4*0  per  cent. 

Albumen. — Abnormal.     See  Albuminuria. 

Sugar. — Abnormal.     See  Diabetes. 

Deposit. — Bulk  in  proportion  to  urine  ;  colour  ;  light  or  heavy. 

CHEMICAL   EXAMINATION   OF   THE   DEPOSIT. 

Phosphates. — Soluble  in  nitric  acid  ;  insoluble  in  liq.  potassse. 
Urine  usually  alkaline. 

Litliates. — Soluble    in  liq.    potassse,  or   on  warming  deposits. 
Urine  when  warm  as  passed  is  clear. 

Uric  acid. — Soluble  in  liq.  potassae,  and  precipitated  from  that 
solution  by  hydrochloric  acid.     See  Murexide  Test. 

AIucus. — Coagulated  by  boiling  with  liq.  potassee. 

MICROSCOPICAL   EXAMINATION   OF   THE   DEPOSIT. 

1.  Casts. — Large,  small,  hyaline,  granular,   epithelial,  contain- 

ing large  swollen  epithelium  ;  blood  casts. 

2.  Crystals. — {a)   Triple  phosphate  :   Triangular  prisms,  often 

large  ;  when  very  short  they  may  be  mistaken  for  octa- 
hedral oxalates.  (&)Uric  acid  :  Usually  coloured  ;  crystals 
regular,  lozenge-shaped  or  square,  elongated  or  acicular. 
(c)  Oxalates  :  Octahedra  with  bright  centres.  Dumb-bells. 
{d)  Cystine  :  Hexagonal  plates. 

3.  E2nthelium. — Glandular  ;  squamous  from  vagina  or  bladder, 

4.  Fus,— 


DISEASES    OF   THE   URINAEY   SYSTEM.  99 


imiNE,   DESCRIPTION   OF. 

Qiiantity. — Increased  in  Diabetes, 

Colour. — May    indicate    Jaundice;    Hsematuria;    greenish     n 

diabetes. 
Reaction. — In  alkaline  urine  usually  a  deposit  of  phosphates. 
Sx>.    gr. — Dense   in   Diabetes,  or  if  much  urea,    etc.     Low  in 

Granular  Contracted  Kidneys. 
Urea. — Usually  a  large  percentage  if  sp.  gr.  is  high  vrithout 

sugar. 
Albumen. — May  be  a  transient  ingredient,  therefore  look  for  it 

repeatedly. 
Suga.r. — Occasionally  present  in  Brain  Disease. 
Deposit. — Give  general,  chemical,  and  microscopical  characters. 

CLINICAL   INDICATIONS    OF   THE   DEPOSIT. 

Pliosipliates. — Common   in   hot  weather,    when   urine   ferments 

readilj''.     Abundant  when  there  is  much  mucus  or  pus. 
Lithates. — Copious  deposit  in  febrile  conditions  and  in  Passive 

Congestion   of  kidneys  ;  also   usually   in  healthy   scanty 

urine. 
Uric  acid. — Like  grains  of  cayenne  pepper.  May  indicate  gouty 

tendency  or  calciilus-formation.     Deranged  liver. 
Mucus. — Copious  in  cystitis. 

1.  Casts. — Coming  from  uriniferous  tubes  indicate  their  condi- 

tion. Numerous  in  acute  Bright' s  Disease  ;  abundant  and 
varied  in  inflammation  ;  few  in  lardaceous  disease  ;  few  in 
cirrhosis  ;  common  in  other  cases  of  albuminuria. 

2.  Crystals. — {a)  Triple   phosphates    are   common  in   alkaline 

urine  in  cystitis,  and  in  urine  that  has  decomposed.  (&) 
Uric  acid  :  Deposited  in  the  gouty  diathesis,  (c)  Oxalates  : 
Dyspepsia  may  produce  oxaluria,  so  anemia,  {cl)  Cystine 
may  form  calculi. 

3.  Epithelium. — Common  in  Bright's  disease. 

4.  Pus  from   a  pelvic    abscess   may    be    discharged   into  the 

bladder  or  urinary  tract.  Copious  in  renal  abscess,  and 
in  cystitis. 


200  CLINICAL   MEDICINE   AND    CASE-TAKING. 


NORMAL    CONSTITUENTS    OF    URINE. 

Chlorides. — A  few  drops  of  nitric  acid,  then  an  excess  of 
solution  of  nitrate  of  silver ;  white  precipitate  of  chloride 
of  silver  thrown  down.  (N.B. — Mtric  acid  prevents 
phosphate  being  precipitated. )  Wash  precipitate  and  prove 
its  solubility  in  ammonia. 

Phosphoric  Acid. — (a)  Solution  of  nitrate  of  silver  gives  a  ■ 
white  precipitate  of  phosphate  of  silver,  soluble  in  nitric 
acid,  but  insoluble  in  ammonia.  (6)  To  urine  tested  as 
below  for  sulphuric  acid,  and  thus  deprived  of  sulphates, 
add  excess  of  ammonia  ;  phosphate  of  baryta  is  thrown 
down. 

Sulphuric  Acid. — Add  a  few  drops  of  niti-ic  acid,  then  chloride 
of  darium,  which  gives  a  white  precipitate  of  the  sulphate. 

Urea.— If  the  sp.  gr.  of  the  urine  be  from  1023—1030  it 
usually  crystallizes  with  an  equal  bulk  of  nitric  acid,  the 
solution  being  cooled.  Beautiful  crystals  of  nitrate  of 
urea  are  formed.     See  quantitative  examination. 

Uric  Acid. — Precipitated  from  urine  by  hydrochloric  a.cid,  and 
waiting  twenty-four  houi^s.  Soluble  in  liq.  potassse.  See 
Murexide  Test. 

(a)  Quantity.* — 1.  Diminished  in  early  inflammatory  conditions. 

2.  Normal  in  middle  inflammatory  stage,  and  in  early 
.  stage  of  cirrhosis. 

3.  Increased  in  lardaceous  kidney,  and  here  may  precede 
albuminuria.  In  cirrhosis,  late  stage.  Sometimes  in  ad- 
vanced inflammation  and  dming  absorption  of  dropsies. 

4.  Suppressed  in  acute  and  adA^anced  inflammation,  and 
in  advanced  cirrhosis. 

(&)    Sp.   Gr.    and    Solids. — Depend   upon  water,    m'ea,     other 

solids. 

*  After  Dr.  Grainger  Stewart. 


DISEASES   OF   THE   URINARY  SYSTEM.  201 


ABNORMAL  CONSTITUENTS   OF  URINE. 

Albumen. — 1,  Heat  urine,  and  when  boiled  add  nitric  acid  ;  a 
precipitate  indicates  albumen. 

2.  Float  in  test-tube  on  nitric  acid  ;  a  non- crystalline 
cloud  at  the  junction  of  the  two  fluids  indicates  albumen. 

Sugar:  Moore s  test. — Mix  urine  with  half  its  volume  of  liq. 
potassse  and  boil ;  a  brownish  colour  shows  sugar. 

Trammer's  test.  — Add  to  urine  one  or  two  drops  of 
solution  of  sulphate  of  copper,  then  about  half  as  much 
liq.  potassse  as  urine.  If  sugar  be  present,  the  precipitate 
at  first  produced  dissolves,  producing  a  blue  solution. 
Now  boil  this  solution  ;  sugar  causes  decomposition,  and 
the  brown  oxide  of  copper  is  precipitated. 

Fehling's  test. — Cupric  sulphate,  40  grammes;  potass, 
tartrat.,  160  grammes;  liq.  sodee  (sp.  gr.  1"12),  750 
grammes  ;  distilled  water  to  1,154*5  c.c.  Boil  some  of 
this  solution  ;  then  add  urine,  a  few  drops  at  first,  and 
if  it  be  saccharine  the  red  suboxide  of  copper  precipitates 
at  once. 

Bile :  Pettenkofers  test. — Dissolve  a  gi'ain  or  two  of  white 
sugar  in  a  drachm  of  urine  ;  then  add,  drop  by  drop, 
strong  sulphuric  acid.  A  characteristic  violet-red  colour 
will  be  produced  if  bile  be  present. 

Leucine.  —  A  morbid  product,  crystallizes  as  small  spheres 
which  are  composed  of  acicular  crystals  which  radiate 
from  a  common  centre. 

Tyrosine. — Crystallizes  in  long  white  needles. 


202  CLINICAL   MEDICINE  AND   CASE-TAKING. 


URINARY  CALCULI. 


Heat  a  specimen  on  platinum  foil  over  spirit  jfiame  ;  afterwards 
witli  blowpipe. 

I.  It  hurns  away,  leaving  only  a  minute  trace  of  ash,  probably 

either  Uric  Acid,  Urate  of  Ammonia,  or  Cystine.  Proceed 
to  test  calculus  with  (a)  liq.  potassse  ;  soluble.  See  Uric 
Acid.  (&)  Soluble  in  hot  water  or  with  liq.  potassfe, 
■  evolving  ammonia  =  urate  of  ammonia.  (c)  Insoluble 
in  hot  water,  but  readily  soluble  in  ammonia,  the  solution 
on  evaporation  giving  hexagonal  plates  —  Cystine. 

II.  It  proves  incoinhustihle  before  the  blow-pipe,  {a)  Soluble  in 
dilute  hydrochloric  acid  =  Phosphate  of  Lime.  Ammonia 
added  to  such  solution  gives  an  amorphous  precipitate. 
(&)  Fusible  before  blow-pipe  and  soluble  in  hydrochloric 
acid  =  Triple  Phosphate.  The  precipitate  produced  by 
ammonia  from  the  solution  is  crystalline.  (c)  Before 
ignition  soluble  without  effervescence  in  hydrochloric 
acid,  this  acid  solution  giving  a  white  precipitate  with 
ammonia.  After  ignition  soluble  with  effervescence  in 
hydrochloric  acid,  this  solution  giving  no  precipitate  with 
ammonia  =  Oxalate  of  Lime. 


DISEASES    OF   Tl^E   FRINARY   SYSTEM.  203 


UEINARY   CALCULI. 

Uric  acid  and  pliospliatic  calculi  common. 


Murcxide  test  of  Uric  Acid. —  Dissolve  the  substance  to  be 
tested  in  nitric  acid,  and  gently  warm  ;  when  cold  touch 
residue  with  liq.  potassee ;  a  beautiful  purple  solution 
indicates  uric  acid 


204  CLINICAL   MEDICINE   AND   CASE-TAKING. 


SIGNS  OF  PREGNANCY. 

General  condition.  — Chloasma. 

Nei'vous  system. — Head-ache.  Altered  mental  condition,  some- 
times great  sleepiness,  at  other  times  insomnia.  Neuralgic 
pains  of  all  kinds. 

Vascular. — Heart  beats  become  more  frequent.  Pulse  of  high 
tension. 

Ee^piratory, — Dyspnoea  on  exertion.     Cough,  reflex. 

Digestive. — Heartburn,  salivation.  Nausea  may  occur  at  once, 
but  commonly  not  till  second  month.  Sense  of  sinking  in 
epigastrium  ;  cravings  for  food. 

Digestive  disturbance. — Appetite  increased  ;  may  be  strangely 
altered  or  perverted.  Vomiting ;  morning  sickness. 
Bowels  disturbed  ;.  piles  from  pressure ;  often  consti- 
pation. 

Urine. — Kyestein  floats  as  a  pellicle  on  urine  after  it  has  stood 
twenty-four  to  thirty-six  hours,  subsequently  falling  as  a 
milky  deposit.     Not  a  sure  sign.     Albuminuria. 

Diagnosis  from  —  Ascites  ;  amenorrhoea  from  other  causes. 
Ovarian  dropsy.     Phantom  tumour  ;  abdominal  tumour. 

Duration  of  pregnancy. — Calculate  the  full  time  complete  at 
forty  weeks,  dating  from  a  fortnight  after  commencement 
of  last  menstruation. 


SIGNS   OF   PREGNANCY.  205 


PEEGNANCY.— COINCIDENT  SIGNS  AND 
SYMPTOMS. 

Sincial  signs  of  pregnancy. — 1.  Suppression  of  tlie  menses, 
under  the  climacteric  age,  and  without  anaemia  or  known 
uterine  disease.      Balottement. 

2.  Changes  in  the  breasts  which  early  become  somewhat 
enlarged,  their  sensitiveness  increased,  with  a  feeling  of 
fulness,  weight,  and  shooting  pains.  Veins  in  skin  en- 
larged, the  glands  feeling  hard  and  knotty,  and  being 
tender,  and  sometimes  subcutaneous  fat  augmented. 
Areola  darkened,  with  a  secondary  areola  outside  ;  moist 
with  enlarged  sebaceous  follicles,  milk  in  breast  in  last 
month.     Nipples  turgid  and  prominent. 

3.  Changes  in  abdomen.  —  No  visible  tumour  till  third 
month.  At  first  umbilicus  is  sunken  from  growth  of  fat ; 
later  it  is  protruded  by  internal  pressure.  Uterine  tumour 
elastic  ;  very  slightly  fluctuating ;  at  fifth  month  reaches 
half  up  to  umbilicus. 

4.  Auscultation  of  uterus.  —  Foetal  heart.  Placental 
souffle. 

Complications. — Obstruction  of  bowels ;  haemorrhage  from  uterus. 

Pressure  signs, — On  bladder.     Piles. 


I  X  D  E  X 


Abdomen,  examination  of,  166 
Abdominal  cancer,  162 

pain,  acute,  156 

pulsation,  167 

tumonr,  166 
Acute  Blight's  disease,  192 
Acute  yellow  atrophy  of  liver, 

179 
Addison's  disease.  28 
Adynamia,  see   Typhoid   state, 

44 
Ague,  12 
Albumen,  201 
Albuminuria,  188 

latent,  189 
Alcoholism,  86 

acute,  88 
Amnesia,  41 

Amphoric  respiration,  128 
Amyloid  degeneration,  24 

kidneys,  192 
Anaemia,  20 

pernicious,  20 
Ansesthesia,  57 

muscular,  56 
Analgesia,  57 
Anasarca,  24 
Aneurism,  120 

abdominal,  169 
Angina  pectoris,  115 
Ankle  clonus,  48 
Aortic  obstruction.  109 


Aortic  regurgitation,  109 

Aphasia,  41 

Aphonia,  149 

Appetite,  150 

Arteries,  122 

Arthritis,  34 

Ascites,  165 

Ascites  or  ovarian  dropsy,  170 

Asthma,  146 

Ataxy>  94 

Atheroma,  123 

Athetosis,  52 

AiU'a,  57 

Auscultation,  128 


Bell's  paralysis,  61 

Bile  in  urine,  201 

Biliary  colic,  182 

Bilious  attacks,  41 

Bladder,  disease  of,  195 

Blood  in  expectoration,  132,  133 

motions,  158 

urine,  190 

vomit,  133,  156 
Bone  disease,  17,  22 
Bowels,  state  of,  150 

obstruction  of,  158 

ulceration  of,  164 
Brain  disease,  64 
Bright's  disease,  184 

acute,  192 


INDEX. 


207 


Blight's  disease,  acute  or  chronic, 

194 
Bronchitis,  146 
Bronzing  of  skin,  29 
Bruit  de  Diable,  21 
Bulbar  paralysis,  70 
Bulging  of  chest,  127 

Calculi,  biliary,  182 

renal,  196 

urinary,  202 
Cancer,  20 

abdominal;  162 

of  intestines,  163 

of  liyer,  177 

of  stomach,  163 
Cardiac  congestion,  106 

dilatation,  111 

displacements,  112 

hyperti'ophy,  110 
Casts,  urinary,  198 
Cerebral  meningitis,  82 

tumour,  82 

vomiting,  45 
Chest,  movements  of,  126 

regions  of,  124 
Children's  case-taking,   xiv 
Chlorides  in  urine,  200 
Chorda  tympani,  61 
Chorea,  76 
Choroiditis,  65 
Chronic  Bright's  disease,  192 
Circumduction,  54 
Cin-hosis  of  liver,  180 
Clonic  spasm,  50 
Colic,  biliary,  182 

renal,  197 
Coma,  42 
Condylomata,  14 
Congenital  defects  of  heart,  118 
Congenital  syphilis,  14 
Congestion,  passive,  106 
Consolidation  of  lung,  137 
Contraction  of  lung,  136 
Convulsion,  50 
Co-ordination  of  limbs,  54 


Cough,  130 

Cracked  pot  sound,  128 
Cramp,  50 
Cranial  nerves,  58 
Craniotabes,  14 
Crepitations,  130 
Cross  paralysis,  70 
Ciystals  in  urine,  199 
Cycloplegia,  67 
Cystine,  202 
Cystitis,  195 

Delirium,  44 

tremens,  87 
Developmental  defects,  31 
Diabetes,  28 
Diarrhoea,  154 
Digestive  functions,  150 
Dilatation  of  heart,  110 
Diphtheria,  8 
Diphtheritic  paralysis,  100 
Diplopia,  58 

Displacements  of  heart,  112 
Dorsal  decubitus,  42 
Drunkenness,  86 
Duchenne's  disease,  70 
Dyssesthesia,  57 
Dysentery,  165 
Dysphagia,  156 
Dyspnoea,  134 

Electric  tests,  46 
Emaciation,  22 
Embolism,  122 
Emphysema,  144 
Empyema,  139 
Enteric  fever,  4 

diagnosis  from  tuberculosis, 
27 
Epilepsy,  78 
Epistaxis,  12 
Erysipelas,  8 

Examination  of  abdomen,  166 
Exophthalmos,  98 
Expectoration,  132 
Extensors,  paralysis  of,  70 


208 


INDEX. 


Face,  paralysis  of,  61,  75 
Facial  nerve,  60 
Facial  palsy,  cerebral,  75 
Facial  spasm,  50 
Fatty  kidneys,  192 
Feliling's  test,  201 
Fever,  signs  of,  2 

enteric,  4 

scarlet,  4 

typh-us,  4 
Fevers,  specific,  4 
Fine  movements,  46 
Functional  paralysis,  47 

Gait,  54 

Gall-stones,  182 

Gasti'ic  crises,  94 

Gastiic  ulcer,  160 

General  paralysis  of  insane,  89 

Girthing  sensation,  57 

Glosso-labio-laryngeal  palsy,  70 

Glosso-pliaryngeal  nerve,  62 

Goitre,  exoplitlialmie,  98 

Gonorrhceal  rheumatism,  38 

Gout,  38 

Granular    contracted    kidneys, 

192 
Graves'  disease,  98 
Gummata,  17 
Gums,  152 

Haematemesis,  156 
Hsematuria,  190 

paroxysmal,  191 
Hfemoptysis,  132 
Haemoptysis   or    Hcematemesis, 

133 
Haemorrhage  in  retina,  65 
Headache,  41 
Head-pain,  40 
Hearing,  58 
Heart,  congenital  defects  of,  118 

dilated  and  hypertrophied, 
110 

disease,  112 

displacements  of,  112 


Heart,  hypertrophy,  110 

physical     examination    of, 
i02 
Hemiansesthesia,  57 
Hemiopia,  41 
Hemiplegia,  74 
Herpes  zoster,  100 
Hooping-cough,  12 
Hydatids,  183 
Hydrocephalus,  84 
Hydrothorax,  139 
HyperEesthesia,  57 
Hyperpyi'exia,  5 
Hysteria,  78 
Hygienic  conditions,  1 

Idiots,  19 

Illusions,  88 
Infantile  paralysis,  96 
Insanity,  88 
Insomnia,  40 

Insti'uctions  for  case-taking,  xi 
additional  for  children,  xiv 
Intelligence,  40 
Intercostal  neuralgia,  72 
Intermittent  hsematuria,  191 
Intussusception,  171 
Iridoplegia,  67 
Iritis,  16 

Jaundice,  causation,  174 
Joints,  34 

Knee-jerk,  46 

Kidney,  tumour  of,  167 

Kidneys,  amyloid,  192 

fatty,  192 

granular  conti'acted,  192 

large  white,  192 

Labio-glosso-larjmgeal  palsy,.  70 
Laryngeal  obstruction,  8,  148 

symptoms,  8,  148 
Laryngitis,  149 
Laryngismus,  52,  149 
LarjTix,  disease  of,  149 


INDEX. 


209 


Lead  poisoning,  98 
Leucine,  201 
Lightning  pains,  69,  95 
Liver,    acute    yellow    atrophy, 
178 

cancer  of,  176 

cirrhosis  of,  180 

large,  176 

small,  178 

syphilitic  diesase  of,  180 
Locomotor  ataxy,  94 

pulse,  104 
Lung  contraction,  136 

solidification,  137 

Malformation  of  heart,  118 
Mania,  post  epileptic,  80 
Marasmus,  23 
Measles,  6 
Melsena,   158 
Meningitis,  82 
Mercurial  tremor,  53 
Michel's  ganglion,  61 
Migraine,  41 
Miliaria,  37 
Minor  paralyses,  70 
Mitral  obstruction,  108 

regurgitation,  108 
Motor  power,  54 
Mouth  and  throat,  152 
Movements  of  extremities,  54 

fine,  46 

of  head  and  trunk,  54 
Mucous  patches,  14 
Muscular  anaesthesia,  56 

movements,  hysterical,  78 
Murexide  test,  203 

Nerve,  recurrent  laryngeal,  62 
superior  laryngeal,  61 

Nervous  system,  40 

Neuralgia,  70 

conditions  characterized  by, 

70 
trigeminal,  72 

N  dules,  rheumatic,  37 


Normal  respii-ation,  128 
Nutrition,  22 
Nystagmus,  58 

Obstruction  of  bowels,  158 
(Edema,  24 

pulmonary,  134 
Ophthalmoplegia  interna,  67 
Ophthalmoscopic  appearances,  64 
Optic  discs,  64 

atrophy,  64 

neuritis,  99 

otorrhoea,  58 
Ovarian  dropsy  or  ascites,  170 
Ovarian  tumour,  167,  170 
Oxalates,  198 

Pain,  abdominal,  156 
Palate,  152 

Palpitation,    functional    or   or- 
ganic, 114 
Palsy  of  cranial  nerves,  58 
Paralysis,  46 

agitans,  90 

diphtheritic,  100 

functional  and  organic,  47 

infantile,  96 

labio-glosso-laryngeal,  70 

of    extensors    of    forearm 
98 

of  face,  61,  75 

of  face.  Bell's,  61 
Paraplegia,  68 
Paroxysmal  hgematuria,  191 
Passive  cardiac  congestio  n,  106 
Patellar  tendon  reflex,  48 
Pernicious  aneemia,  20 
Pericarditis,  116 
Periostitis,  16 
Peritoneum,  flidd  in,  168 
Peritonitis,  172 
Phantom  tumour,  171 
Pharynx,  152 
Phlebitis,  123 
Phosphates,  198 
Phosphoric  acid,  200 


^m 


mm 


